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LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA. 






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SEP 



1885 



A TREATISE 



NEKVOTTS DISEASES; 



SYMPTOMS AND TREATMENT. 



A TEXT-BOOK FOR STUDENTS AND PRACTITIONERS. 



BY 

SAMUEL G. ' WEBBER, M.D., 

CLINICAL INSTRUCTOR IN NERVOUS DISEASES, HARVARD MEDICAL SCHOOL ; VISITING 
PHYSICIAN FOR DISEASES OF THE NERVOUS SYSTEM AT THE BOSTON CITY HOS- 
PITAL ; MEMBER OF THE MASSACHUSETTS MEDICAL SOCIETY ; MEMBER 
OF THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC., ETC. 






//*'/•&' 



NEW YORK: 
D. APPLETON AND COMPANY, 

1, 3, and 5 BOND STREET. 

1885. 



1t( 



COPTEIGHT, 18S5, 

Bt D. APPLETON AND COMPANY. 



PREFACE. 



This book was commenced with the purpose of 
writing briefly, and including what is most essential 
for the study of nervous diseases, within as small a 
compass as possible. The limits originally marked 
out have been somewhat exceeded. The histories 
of discoveries, reports of cases, and discussions of 
disputed points have been omitted ; the opinions of 
different observers have been alluded to only rarely. 
An effort has been made to describe the symptoms 
with sufficient detail to render easy the recognition of 
a case in practice. My own views have been formed 
from observation and from reading the opinions of 
others ; to give proper credit in every instance might 
be impossible. The attempt has not been made. Of 
course, in the brief Bibliographies only a few authors 
could be mentioned, compared with the large number 
who have contributed to an increase of our knowl- 
edge during the last few years. 

The book is not written for specialists. Many 
will probably find that no department or division 
is so fully treated as they may sometimes wish. I 



iv PREFACE. 

trust that students and general practitioners who 
have little time to read will find what they most 
need for diagnosis and treatment of the cases occur- 
ring in practice. In some parts, especially the intro- 
ductory chapters, the condensation may seem to have 
been carried too far ; but more extensive descriptions 
would have required an increase in bulk. 

133 Botlston Street, Boston, 
June 1, 1S85. 



CONTENTS 



CHAPTER I. 

PAGE 

General Introduction 1 

Methods of Testing Sensation, 1 ; Methods of Testing Motion, 5 ; 
Reflexes, 8 ; Tdche Cerebrate, 9 ; Cheyne-Stokes Respiration, 10 ; Bed- 
Sores, 10; Constipation, 11; Cystitis, 12; Nutrition, 12. 



DISEASES OF THE BRAIN. 

CHAPTER II. 
Introductory 17 

Anatomy, 18 ; Physiology, 33 ; General Symptomatology, 3*7 ; 



Disturbances of Speech, 46. 

CHAPTER III. 

Diseases of the Membranes 50 

External Pachymeningitis, 50; Internal Pachymeningitis, 51; 
Simple Inflammation of the Pia Mater, 53 ; Tubercular, 61. 

CHAPTER IV. 

CnANGE in Blood-Supply 68 

Cerebral Anaemia, 68 ; Cerebral Hypersemia, 74. 

CHAPTER V. 
LI^ilORRHAGE 84 

Meningeal Haemorrhage, S4; Cerebral Haemorrhage, 86. 

CHAPTER VI. 

Occlusion of Cerebral Arteries " 107 

Embolism, 107; Thrombosis, 112. 



vi CONTENTS. 

CHAPTER VII. 

PAGE 

TUMOES OF THE BbAIN 116 

CHAPTER VIII. 
Abscess of the Bbain 124 



DISEASES OF THE SPINAL CORD. 

CHAPTER IX. 

Anatomy of the Spinal Coed • . 131 

Physiology of the Spinal Cord, 136 ; General Symptomatology, 
138. 

CHAPTER X. 
Spinal Meningitis 149 

Pachymeningitis Interna, 149 ; Inflammation of the Pia Hater 
(Leptomeningitis), 152. 

CHAPTER XI. 
Changes in Blood-Supply 156 

Spinal Hyperemia, 156; Spinal Anaemia, 158. 

CHAPTER XII. 

Spinal H-emoeehage 159 

Meningeal Haemorrhage, Haematorrhachis, 159; Haemorrhage 
into the Spinal Cord, Haematomyelitis, 162. 

CHAPTER XIII. 

Slow Compeession of the Spinal Coed 167 

Spinal Tumors, 1*73. 

CHAPTER XIY. 
Syeingomyelia. — Foemation of Cayities. — Hydeomyelus . 176 

CHAPTER XV. 

Myelitis, Acute 179 

Chronic, 188; Acute Ascending Paralysis, 192. 



CONTENTS. v ii 

CHAPTER XVI. 

PAGE 

Poliomyelitis. Myelitis of the Anterior Coenua . . . 195 
Acute Anterior Poliomyelitis, 195 ; Chronic Anterior Polio- 
myelitis, 202. 

CHAPTER XVII. 
Progressive Muscular Atrophy ...... 207 

CHAPTER XVIII. 

Bulbar Paralysis (Labio-Glosso-Laryngeal Paealysis) . . 215 
Acute Bulbar Paralysis, 222. 

CHAPTER XIX. 

Locomotor Ataxia. — Tabes Dorsalis. — Posterior Spinal Scle- 
rosis 224 

CHAPTER XX. 

Sclerosis. — Multiple Sclerosis 242 

Sclerosis of the Lateral Columns, 250; Amyotrophic Lateral 
Sclerosis, 252. 

CHAPTER XXI. 
Pseudo-Hypeetrophio Paralysis 255 



DISEASES OF THE PERIPHERAL AND SYMPATHETIC 
NERVES. 

CHAPTER XXII. 
Simple Neuritis 261 

Multiple Neuritis (Disseminated Neuritis), 266. 

CHAPTER XXIII. 

Neubalgia 270 

Trifacial Neuralgia (Prosopalgia), 274; Cervico-Occipital Neu- 
ralgia, 2H; Cervico-Brachial Neuralgia, 275; Dorso-Intercostal 
Neuralgia, 275 ; Lumbo-Abdominal Neuralgia, 276 ; Sciatica, 276. 



viii CONTENTS. 

CHAPTER XXIV. 

PAGE 

Local and Post-Febrile Paralysis 285 

Peripheral Paralysis, 285 ; Special Forms of Paralysis, 289 ; 
Paralysis of Ocular Nerves, 289 ; Paralysis of Seventh Nerve, 289 ; 
Paralysis of the Brachial Plexus, 293 ; Paralysis after Acute Dis- 
eases, 294 ; Diphtheritic Paralysis, 295. 

CHAPTER XXV. 
Spasm 298 

Facial Spasm, 299 ; Torticollis, or Wry-Neck, 301 ; Spasm of 
the Diaphragm, 303 ; Professional Cramp, 304. 

CHAPTER XXVI. 

Diseases of the Sympathetic 307 

Cephalalgia, Headache, 307 ; Megrim, Sick Headache, Migraine, 
311; Graves's Disease (Exophthalmic Goitre), 316; Angina Pec- 
toris, 318 ; Symmetrical Gangrene, 322 ; Unilateral Facial Atrophy, 
324. 



UNCLASSIFIED. 

CHAPTER XXVII. 
Vertigo 329 

Meniere's Disease, 330. 

CHAPTER XXVIII. 
Chorea 332 

CHAPTER XXIX. 
Paralysis Agitans. — Shaking Palsy.— Parkinson's Disease . 339 

CHAPTER XXX. 
Epilepsy 342 



CHAPTER XXXI. 
Hysteria 

Hystero-Epilepsy, 360. 



CONTENTS. lx 

CHAPTER XXXII. 

PAGE 

Netjeasthenia 371 

CHAPTER XXXIII. 

Tetanus (Locked-Jaw) ........ 379 

Tetany, 383. 

CHAPTER XXXIV. 
Mtxcedema 386 

CHAPTER XXXV. 

Toxio Neueosis 389 

Chronic Lead-Poisoning, 390 ; Arsenic, 394 ; Alcohol, 395 ; 
Hydrophobia, 399. 

CHAPTER XXXVI. 
Syphilis 403 

Syphilis of the Brain, 403 ; Syphilis of the Spinal Cord, 408 ; 
Syphilis of the Nerves, 409 ; Treatment of Syphilis of the Nervous 
System, 409. 



A TREATISE 

ON 

NERVOUS DISEASES. 



CHAPTER I. 

GENERAL INTRODUCTION. 

Eulenburg, A., Lehrbuch der functionellen Nervenkrank- 
heiten. Berlin, 1871.— Ziemssen, Cyclopaedia of the Practice of 
Medicine. Vols. XI, XII, XIII, XIV.— Eosenthal, M., A Clin- 
ical Treatise on the Diseases of the Nervous System. Trans, by 
L. Putzel. New York, 1879.— Hammond, William A., A Treatise 
on the Diseases of the Nervous System. New York, 1881. — Ham- 
ilton, A. McL., Nervous Diseases : their Description and Treat- 
ment. Philadelphia, 1881. — Charcot, J. M., Lectures on the Dis- 
eases of the Nervous System, delivered at La Salpetriere. Trans, 
by George Sigerson. New Sydenham Society, 1877, 1881. — Gr as- 
set, J., Maladies du systeme nerveux. 1881. — Buzzard, T., Clini- 
cal Lectures on Diseases of the Nervous System. Philadelphia, 
1882.— Axenfeld, A. (Huchard), Traite des nevroses. Paris, 1883. 
— Eoss, James, A Treatise on the Diseases of the Nervous System. 
2 vols. New York, 1883.— Strumpell, A., Krankheiten des Ner- 
ven-systems. Leipzic, 1884. 

It will be an advantage to consider in a general way 
the methods of examining sensation and motion in pa- 
tients affected with nervous diseases. It will prevent 
the necessity of repetition if certain symptoms or com- 
plications are also considered in this introductory 
chapter. 

METHODS OF TESTING SENSATION. 

Changes of sensation of touch may be recognized 
by touching the patient as lightly as possible with the 
l 



2 A TREATISE ON NERVOUS DISEASES. 

finger or a feather. The finger should be kept still, on 
the spot first touched ; if it is moved about, rubbing 
the skin, the patient will much more readily recognize 
that he has been touched. 

The temperature of the finger should be as nearly 
as possible equal to that of the body ; otherwise the 
difference in temperature is felt. 

Changes in the sensation of pressure may also be 
recognized with the finger by varying the amount of 
pressure and asking the patient whether it is greater 
or less. There are various apparatus for more deli- 
cately testing this sense by means of adding graduated 
weights, but these are unnecessary for ordinary pur- 
poses. 

In testing the sense of pain, a pin or a knife can be 
used, or the patient can be pinched with varying de- 
grees of severity. If one or two hairs on the patient's 
limbs are pulled, the sensation will be very nearly the 
same as if a pin were stuck into that place. 

Changes in the sensation of temperature may be ex- 
amined by means of spoons dipped in tumblers of water 
of different temperature. More delicate methods of ex- 
amining the variations in the sense of temperature may 
be found in having small bottles full of water of differ- 
ent temperatures. The patient is then asked whether 
the temperature of one is higher or lower than that of 
another. But these are rather refinements of examina- 
tion, which are rarely of any great practical value. 

The muscular sense may be tested by asking the 
patient, with his eyes shut, to move his limbs in differ- 
ent directions, or to find his feet in the bed, or, when 
the limbs are widely separated, to raise one foot and 
put it down by the side of the other. 

The (Bsthesiometer is used in testing the ability of 
the patient to recognize whether one or two points touch 
the surface of the body. A rough form of sesthesiom- 
eter may be contrived by holding two pins in the fin- 
gers and, varying the distance of their points, touching 



GENERAL INTRODUCTION. 3 

the patient with, them ; or needles may be stuck in a 
piece of wood, and then the patient touched. There 
are, however, many simple instruments for this exami- 
nation, as compasses with a graduated scale, or points 
sliding on a graduated rod. In making this examina- 
tion, it is necessary that both points should touch the 
skin together with as nearly as possible equal force. 
In examining the opposite sides of the body, the points 
should be either transverse on both sides, or parallel 
with the axis of the limb on both sides. They should 
not be transverse on one side and longitudinal on the 
opposite. 

The various sensations may be more acute than nor- 
mal — hyperesthesia ; or less acute — anaesthesia ; or 
there may be a perceptible delay in their recognition. 
Occasionally, when only two points are applied to the 
skin, the patient will have a sensation as if three or 
more touched him. 

The vision may be affected in several ways. There 
may be partial blindness (amblyopia), or there may be 
entire blindness, or various other changes ; — diplopia, if 
the axes of the two eyes are not parallel. This defect 
may be present only when the patient looks in cer- 
tain directions, if one muscle is weaker than the corv 
responding muscle on the opposite side, so that the 
diplopia may not be noticed unless the patient looks to 
the right or left, or upward or downward. Vision may 
be limited in extent, so that the patient sees only ob- 
jects placed directly in front of him. Or, more rarely, 
central vision may be wanting, and only objects around 
the periphery of the field of vision may be recognized. 

The extent of vision for white light may be normal, 
or nearly normal, but the field of vision may be circum- 
scribed for colors. 

The extent at which colors can be seen is naturally 
not so great as the extent at which white can be seen ; 
thus, the field of vision for green is the most contracted, 
next in extent is the field for red, then blue, then yel- 



4 A TREATISE OK NERVOUS DISEASES. 

low. In some cases, the field of vision, instead of be- 
ing limited concentrically, is lost on one side, so that 
the patient sees only that part of an object which is to 
the right or left of the median line. This is called he- 
miopia, as referred to the retina, or hemianopsia, as 
referred to the field of vision. 

If accuracy is required in an examination, it is ne- 
cessary to use a blackboard with a point of fixation, 
the patient being placed at a distance of a foot from 
that point, with one eye covered ; a bit of white paper 
or chalk is then moved from the outside inward until 
the patient can see it, and a mark is made on the board. 
This is repeated at short intervals around the central 
spot until we have mapped out roughly the field of 
vision of the eye. 

It is generally sufficient, however, with the patient 
sitting in front of the physician, with one eye covered, 
the other eye fixed upon the center of the physician's 
face, for the physician to move his fingers first one side 
and then the other, above and below, and inquire 
whether the patient sees the motion of the fingers. 
Sometimes the field of vision for white is natural, or 
nearly natural, but colors can be recognized only in one 
lateral half of the field of vision — hemianacropia ; for 
testing such a change, the blackboard, with bits of 
colored paper, would be necessary. 

The ophthalmoscope is absolutely necessary in 
order for a satisfactory examination of patients with 
diseases either of the brain or of the spinal cord, and it 
is better to use it in every case, no matter what the dis- 
ease may be supposed to be. 

To give any satisfactory description of the use of 
the ophthalmoscope would require altogether too much 
space, a short description being very unsatisfactory. 
It is better to refer to books on ophthalmology for such 
description. 

It is very necessary to examine the pupils, to note 
changes in their reaction to light and to accommoda- 



GENERAL INTRODUCTION. 5 

tion, to notice whether both pupils act alike, or whether 
there are differences between the two. In examining 
the pnpils, it is necessary to cover the one not nnder 
observation, as otherwise the light, falling npon the 
sound eye, may cause contraction, when, if examined 
separately, the pupil would remain immovable. 

METHODS OF TESTING MOTION. 

The motor power may be examined by simply 
watching the movements of the patient. With chil- 
dren, it is a good plan to allow them to roam about the 
room, playing with whatever attracts their fancy. 

With adults, one can watch their gait as they enter 
the room, their manner of taking a seat or executing 
other motions ; if it is necessary for them to undress, 
the way in which they take off their clothing should be 
noted. Much can be learned by thus carefully watch- 
ing the ordinary motions of patients. 

If it is desired to recognize clearly slight losses of 
power in the limbs, the dynamometer may be used. 
There are several different forms of this instrument ; 
the simplest is the best. It is not necessary to estimate 
the exact power, in pounds, of pressure, but it should 
be possible, from the scale of the dynamometer, to esti- 
mate the relative power of the two sides of the body, 
A rough idea of the relative strength of the two hands 
can be gained by allowing the patient to squeeze one's 
hand. 

Slight fibrillary twitchings of the muscles may 
sometimes be excited, if they do not occur spontane- 
ously, by snapping the muscles with the finger. The 
natural tone of the muscle is also indicated by the 
energy with which a single contraction takes place 
under the snapping of the finger. 

The most delicate test of muscular power is elec- 
tricity. Under some circumstances the muscle loses its 
power of responding to the irritation of the faradic or 



6 A TREATISE OF NERVOUS DISEASES. 

the galvanic current. Any muscle which is separated 
from its centers of nutrition in the spinal cord under- 
goes the above change of reaction, whether the disease 
is a destruction of those trophic centers or of the nerve- 
fibers passing from them to the muscle. 

The first change noticed in the muscle may be a 
slight and temporary increase of irritability for both 
forms of electricity. A day or two afterward the mus- 
cle begins to lose its power of reacting to the f aradic 
current. By the end of the second or third week it no 
longer responds to this stimulus. After a slight dimi- 
nution of reaction to the galvanic current, during the 
second week the irritability of the muscle for this cur- 
rent increases until it becomes much greater than nor- 
mal. This increased irritability for the galvanic cur- 
rent may continue for many weeks or months, but at 
length is gradually lost, until, if the paralysis is perma- 
nent, the muscle responds to neither current. 

With this change in the amount of irritability there 
occurs a difference in the manner in which the muscle 
reacts to the galvanic current. Instead of the natural, 
rapid, spasmodic contraction, the muscle contracts 
slowly, the contraction reaching its height only after 
a perceptible interval of time, and then slowly relax- 
ing — a change that is very evident, even to the un- 
skilled observer. 

There are also changes in the quality of the reaction 
to the galvanic current, according as the positive or 
negative pole is placed upon the muscle, and the cur- 
rent closed or opened. These changes are of less prac- 
tical value, and can be learned from works on electro- 
therapeutics. 

This " reaction of degeneration" is of great im- 
portance in diagnosis. 

Reflex actions play an important role in the internal 
economy of the body, and in its relation with the ex- 
ternal world. 

An impression made upon an afferent nerve is car- 



GENERAL INTRODUCTION. ? 

ried to a group of nerve-cells ; by means of these, alone 
or in connection with other groups, it is transformed 
into a motor impulse, which is carried by efferent 
nerves to muscles, and causes them to contract. This 
is the simplest form of a reflex action. The muscles 
excited are usually those nearest the point receiving 
the irritation. If, however, the irritation is severe, dis- 
tant muscles may be brought into action, even those on 
the opposite side. The muscles may not be voluntary ; 
they may belong to internal organs, as stomach, intes- 
tines, bladder ; the impression may be made upon these 
viscera, not on the surface of the body ; the groups of 
nerve-cells may not be in brain or cord, but in one of 
the sympathetic ganglia, or in the walls of the viscus. 

The impressions upon the special senses may give 
rise to reflex actions confined to the organ receiving the 
impression, as movements of the iris, contraction of 
the intrinsic muscles of the ear ; or the impression may 
be so strong as to call into action other muscles of the 
body, as when a loud noise or bright flash causes the 
head to turn, or sets the heart beating violently. 

Reflex actions control, in a very large degree, the 
secretions of the different glands and the supply of 
blood to various parts of the body. 

Thoughts and emotions have a great influence upon 
the circulation, the secretions, and the nutrition of the 
body ; this influence is generally reflex in its nature, 
and may often be utilized in the treatment of disease. 

It is not necessary that the brain should take cogni- 
zance of the impressions which excite reflex action ; in- 
deed, these actions are often more powerful when the 
subject is unconscious of the impression exciting them, 
as when the spinal cord is divided. 

The reflex centers for the different groups of mus- 
cles in the limbs are situated at about the level whence 
the nerves supplying those muscles arise. There are 
reflex actions which follow an irritation of the skin — 
cutaneous reflexes ; also actions which follow irritation 



8 A TREATISE ON NERVOUS DISEASES. 

of deeper parts, of which the tendon reflexes are ex- 
amples. 

The various reflexes require a separate description, 
Gowers has given the clearest account of these. By 
gently irritating the skin, by tickling, scratching, or 
pricking, the superficial or cutaneous reflexes may be 
excited. Gowers mentions the plantar (from the sole 
of the foot), depending on the lower part of the lumbar 
enlargement ; the gluteal, by irritating the skin of the 
buttocks, depending on the cord at the level of the 
fourth or fifth lumbar nerve ; the cremaster, by which 
the testicle is drawn up when the skin on the inner 
aspect of the thigh is irritated, depending on the first 
and second lumbar pairs ; the abdominal, by irritating 
the skin at the side from the ribs downward, depending 
upon the eighth to the twelfth dorsal nerves ; the epi- 
gastric, produced by irritating the side of the chest in 
the fourth to the sixth intercostal spaces, depending 
upon the fourth to the seventh dorsal nerves. There 
are sometimes reflexes on the back, caused by irritating 
the skin along the edge of the erector-spin?e muscles ; 
and when the skin between the scapula3 is irritated, 
some of the scapular muscles contract, the scapular 
reflex. 

The deep reflexes, as they are sometimes called, in- 
clude the clonus and tendon reflexes. The more com- 
mon are the 'patella tendon reflex, and that developed 
just above the elbow. To obtain these, the limb should 
be semi-flexed, should hang free without voluntary 
muscular tension ; a sharp blow just below the patella, 
on its ligament, or on the tendon just above the olec- 
ranon process, produces a sudden contraction of the 
muscle and partial extension of the limb. To examine 
for the patellar tendon reflex, the patient should sit on 
a high chair or table, with the legs swinging free ; or, 
if the feet rest on the floor, one leg may be thrown over 
the opposite knee, or the physician can pass his arm 
under the knee, resting his hand on the other knee, the 



GENERAL INTRODUCTION. 9 

leg hanging free over his arm. For the examination 
of the triceps humeri tendon reflex, the patient's arm, 
semi-flexed, should be supported so that the forearm 
can move with moderate freedom. Tendon reflexes are 
occasionally found with other tendons. 

Ankle-clonus is excited by holding the patient's leg 
extended, or very slightly flexed on the thigh ; then, by 
suddenly flexing the foot, and perhaps the toes too, 
the Achilles tendon and the flexors of the toes are put 
on the stretch ; then a rhythmic contraction and relaxa- 
tion of the calf muscles occur, which continue as long 
as the proper degree of flexion of the foot is maintained. 
Sometimes a strong pressure on the sole of the foot is 
needed to develop this, and sometimes only a very light 
pressure, the stronger checking the clonus. The clonus 
can sometimes be excited by a similar flexion of the 
wrist-joint. When the reflex excitability is much ex- 
aggerated, it may be possible to obtain a clonus in the 
toes or fingers. 

The front tap contraction, which Gowers says is a 
very delicate test of increased irritability, is obtained 
by keeping the leg nearly extended on the thigh, the 
foot moderately flexed so as to keep the tendo- Achilles 
slightly tense, then a gentle tap with the ends of the 
fingers is made over the edge of the tibia. The calf 
muscles contract, drawing the foot down ; the action is 
usually very slight, and is the stronger the nearer the 
ankle the tap. 

A tap over the head of the tibia will sometimes pro- 
duce a contraction of the rectus femoris ; or a tap over 
the radius at the wrist will cause contraction of the 
biceps ; over the ulnar at the wrist, of the triceps. 

TacTie cerebrate is developed by drawing the finger- 
nail or the finger across the skin, especially over the 
abdomen. A red line appears after a variable length 
of time, corresponding to the tract of irritation. This 
line can be produced in a large majority of patients. 



10 A TREATISE ON NERVOUS DISEASES. 

It is of value as a symptom only when it appears very 
quickly and is of a deep color ; the line made with the 
nail is brighter than the broader line made with the 
finger. At the side of the red line the skin seems to 
acquire a paler tint, as if the smaller vessels were con- 
tracted. This sign is of less value than was formerly 
supposed. 

Cheyne-StoJces respiration, named from those who 
first described it, consists of a peculiar rhythmical 
change in the breathing. After a pause, in which two 
or three respirations are lost, the lungs are again filled, 
the breathing slowly increases in rapidity until a limit 
is reached ; the frequency then diminishes until there is 
another pause. This succession of respiratory acts is 
then repeated. This symptom is a very serious one, 
and almost always indicates a fatal termination. 

Bed-sores form with extreme rapidity in some cases 
of lesion of the spinal cord, as the result of irritation 
of the cord; at other times they are slow in appear- 
ance. They are among the most annoying complica- 
tions, and sometimes give great discomfort. 

Perfect cleanliness, bathing the skin after every 
passage, changing the bedding when wet or soiled, are 
absolutely necessary to prevent their occurrence. When 
the j>atient can be moved, his j>osition should be changed 
to relieve pressure. The whole back, especially the 
sacral region, should be bathed daily with strong al- 
cohol. 

When the skin becomes discolored and a bed-sore 
seems imminent, even greater care should be taken in 
bathing, that spot be relieved from pressure, and, if the 
skin is broken, zinc ointment may be used. Further 
mischief may sometimes be thus avoided. If a slough 
forms, the best treatment is the alternate use of ice and 
poultices — ice for two or three minutes, then poultice 
for two or three hours. Of course, the offensive dis- 
charges must be removed ; where the edges are under- 
mined, a gentle stream of water from a fountain syringe 



GENERAL INTRODUCTION. 11 

must be used to wash out the pockets holding the dis- 
charge. Carbolic acid, thymol, phenol, or similar sub- 
stances, may be sprinkled on the poultices. A char- 
coal poultice is sometimes of benefit. 

Various water-beds, air-beds, and fracture-beds are 
in use for these cases, and may answer a good end. 

A mild galvanic current has been recommended, 
obtained by a silver plate on the sore, connected by 
wire with a zinc plate over the sound skin, and a piece 
of wet cloth placed between the zinc and the skin. 

Constipation accompanies many nervous affections, 
whether organic or functional. Violent means to reme- 
dy this are rarely desirable. Hyoscyamus, belladonna, 
nux vomica, can be added to prescriptions or given in- 
dependently, and may relieve the bowels sufficiently. 
If these are not sufficient, small doses of compound 
extract of colocynth may be added. Unless there is 
some contra-indicaf ion for strychnia, the following may 
prove serviceable : 

$ Ext. colocynth. comp., gr. \ to 2 ; 

Ext. belladonnse, gr. \ to \ ; 

Ext. nucis vomic, gr. \ to \. 

M. Fl. pil. 

A half -grain or grain of ipecac may be added to this 
with advantage if there is slight gastric disturbance. 
This should be given from once to three times daily, as 
may be necessary. 

Drinking copiously, especially a large supply of 
water, hot or cold, early in the morning, will many 
times be all that is necessary. 

In lesions of the spinal cord, more energetic cathar- 
tics may be needed ; aloin or podophyllin, with bella- 
donna or hyoscyamus, can be given in small pills. Ex- 
tract of colocynth may be combined with these. Ene- 
mata of soap-suds or castor-oil, or both, may be needed 
to assist the drugs. It is very desirable to avoid im- 
paction of the fffices. 



12 A TREATISE ON NERVOUS DISEASES. 

If a stool has been long delayed, an enema of six to 
sixteen ounces of olive-oil, retained two or three hours, 
then followed by a pint or more of soap-suds, will often 
produce a motion with comparatively little discomfort 
to the patient. Of course, the physician should judge of 
the size of the enemata by the condition of the patient. 
A " fountain syringe " is much preferable to others. 

Cystitis is frequently a troublesome complication 
in cases of paralysis. It is most frequently associated 
with lesions of the spinal cord, and sometimes is rather 
early in its appearance. Whenever there is retention 
of urine, there is danger lest, being only partially evacu- 
ated, the residue should become alkaline, and phos- 
phatic sediments form ; the decomposed urine is a 
source of irritation, and inflammation of the bladder is 
set up ; this inflammation may extend to the ureters 
and kidneys, giving rise to much distress, and being 
itself a source of exhaustion and danger. 

The bladder should be emptied by catheter twice a 
day. A long rubber tube attached to the end of the 
catheter, hanging into a vessel on the floor by the side of 
the bed, helps to keep the bed dry, and acts as a siphon 
to more thoroughly empty the bladder. If the urine 
becomes alkaline, benzoic acid, five grains thrice daily, 
or boracic acid, or salicylic acid, may be given. The 
bladder should be washed out at least once a day with 
a double catheter, using a weak solution of carbolic acid 
or nitrate of silver ; the latter can be used of a strength 
of three or four grains to the ounce every third to sixth 
day. 

The diet should be easily digestible with mild 
drinks. 

The nutrition of patients is often below normal. It 
is a task to eat when there is no appetite, and the pa- 
tient, yielding to his aversion for food, eats little ; grad- 
ually the whole system suffers, yet there is no demand 
for more food ; the system becomes accustomed to the 
lowered standard of nourishment. 



GENERAL INTRODUCTION. 13 

Many times the greatest patience and tact is needed 
to restore the lost strength. It is generally better to 
give food frequently in small quantities than to try to 
increase the amount taken at one time. The intervals 
may be as near as every half -hour or hour. 

Milk is the most convenient food. It can be made 
more palatable by adding salt, and more digestible by 
adding lime-water, half an ounce to six ounces of milk, 
or five grains of bicarbonate potassa or soda to the same 
amount. It should be slowly sipped, or taken with a 
teaspoon — not drank : one to three quarts a day, ac- 
cording to how much else is taken. Koumiss is a pleas- 
ant and easily digestible form of milk ; directions for 
making it are given in the Dispensatory. 

Eggs, if perfectly fresh, are usually acceptable pre- 
pared in various ways. It is very hard to obtain per- 
fectly fresh eggs in a city ; most city eggs are some- 
what stale, and sometimes, if eggs are laid in musty 
hay, they acquire a disagreeable flavor ; in either case 
patients may not be able to enjoy them. Eggs should 
not be fried. 

Fat is an important article of diet for nervous pa- 
tients. Often too little is taken. Cod-liver oil is ex- 
cellent if it can be taken; if not, cream and butter may 
be used as substitutes. 

Butter should not be heated above the boiling-point 
for water, and should not be used for cooking. 

A powder of beef, which is made by J. Fere, im- 
ported by E. Fougera & Co., New York, forms a valu- 
able article of diet in many cases. It can be mixed 
with water or milk ; it is already cooked. The ordinary 
beef-teas and essences are of very small value as food. 

Sometimes it may be necessary to feed with a stom- 
ach-tube. This may be passed twice or even three 
times a day, and it is much better to use it than to 
have a patient live half starved. In hysteria and in- 
sanity it is sometimes absolutely necessary to thus feed 
a patient. 



U A TREATISE ON NERVOUS DISEASES. 

When there is obstinate vomiting, it may be well to 
let the stomach rest a few days, giving only small pieces 
of ice ; then begin with small amounts of food, gradu- 
ally increasing. 

Patients may be fed by the rectum, using partially 
digested meat, milk, or, better than these, an egg beaten 
up with ten grains of pepsin. Generally an egg or two 
can be given in this way every five or six hours ; it is 
better to wash out the bowels once in twenty-four to 
forty-eight hours with a warm- water enema, Nutrient 
enemata should have a temperature of about 95° to 100°. 
If not too much exhausted at first, patients can be 
sustained for a fortnight or more in this way. 



DISEASES OF THE BRAIN. 



CHAPTER II. 

INTRODTTCTOKY. 

Anatomy.— Henle, J., Handbuch der Nervenlehre des Men- 
schen. — Weenicke, C, Lehrbuch der Gebirnkrankbeiten, Bd. I. 
— Schwalbe, G., Lebrbucb der Neurologie (Hoffmann's Lehrbucb 
der Anatomie des Menschen, 2. Bd., 2. Abt.).— Ranney, A. L., The 
Applied Anatomy of the Nervous System. — Ecker, A., The Cere- 
bral Convolutions of Man. Trans, by Robert T. Edes. 1873. — 
Duret, H., Recherches anatomiques sur la circulation de l'en- 
cephale. Arch, dephysiol., normal et pathol., 1874. — Duval, M., 
Recherches sur l'origine reelle des nerfs craniens. J. de Vanat. 
et de la physiol. , xii-xvi. , 1876-80. 

Physiology.— Fritsch und Hitzig, Ueber die electrische Erreg- 
barkeit des Grosshirns. Reichart und Du Bois-Reymond's 
Arch., 1870. — Ferrier, Experimental Researches in Cerebral 
Physiology and Pathology. West Riding Asylum Med. Rep., 
1873.— Ibid., The Functions of the Brain. 1876.— Ibid., The Lo- 
calization of Cerebral Disease. New York, 1879. — Charcot, J. M., 
Lectures on Localization in Diseases of the Brain. Trans, by E. P. 
Fowler. New York, 1878.— Carville, C, and Duret, H., Sur 
les functions des hemispheres cerebraux. Arch, de physiol., 
1875.— Dodds, W. J., On the Localization of the Functions of the 
Brain : being an Historical and Critical Analysis of the Question. 
Jour, of Anat. and Physiol., 1878. — Seguin, E. C, Lectures on 
the Localization of Spinal and Cerebral Disease. N. Y. Med. 
Record, 1878. — Pitres, J. A., Recherches sur les lesions du cen- 
tre ovale des hemispheres cerebraux, etudiees au point de vue des 
localisations cerebrales. Versailles, 1877. — Exner, Sigmund, Un- 
tersuchungen iiber die Localisation der Functionen in der Gross- 
hirnrinde des Menschen. Wien, 1881. — Munk, Hermann, Ueber 
die Functionen der Grosshirnrinde. Berlin, 1881. — Fere, Ch., 
Contribution a l'etude des troubles fonctionelles de la vision par 
lesions cerebrales. Paris, 1882. — Wadsworth, O. F., Three Cases 
of Homonymous Hemianopia. Boston Med. and Surg. Jour., 
May 22, 1884, p. 483.— Wilbrand, H., Ueber Hemianopsie und ihr 
Verhaltniss zur toplschen Diagnose der Gehirnkrankheiten. Ber- 
lin, 1881. — Ibid., Ophthalmiatrische Beitrage zur Diagnostik der 
Gehirnkrankheiten. Wiesbaden, 18S4. 



18 



DISEASES OF TEE BRAIN. 
ANATOMY. 



The accompanying diagrams from Ecker, with ex- 
planations, will illustrate better than any verbal de- 
scription the nomenclature of the convolutions. 

r 

cm. 




Fig. 1. — View of brain from the side. (Ecker.) 
F, frontal lobe ; P, parietal lobe ; 0, occipital lobe ; T, temporal lobe ; S, fis- 
sura Sylvii ; S', horizontal, <S", ascending branch ; c, sulcus centralis, fissure of 
Eolando; A, anterior central convolution, ascending frontal convolution; £, pos- 
terior central convolution, ascending parietal convolution ; F u upper (or first), 
F 2 , middle (or second), F 3 , lower (or third) frontal convolution. (Occasionally 
these are numbered from below upward. The above is the more generally received 
nomenclature.) /,, upper, /„, lower, f 3 , vertical (prsecentral) frontal fissure ; P lt 
upper, P 2 , lower parietal lobule ; P 2 , gyrus supramarginalis («' is on the same 
gyrus) ; _P 2 ', gyrus angularis. (This passes around the posterior end of the first 
temporal fissure, uniting the first temporal and supramarginal convolutions with 
the second temporal convolution.) ip, sulcus interparietalis ; cm, end of the sul- 
cus calloso-marginalis ; O u first, 6> 2 , second, 3 , third occipital convolution ; po, 
fissura parieto-occipital, internal perpendicular fissure ; o, sulcus occipitalis trans- 
versa; o 2 , sulcus occipitalis longitudinalis inferior ; T u first, T%, second, T 3 , third 
temporal convolution ; £,, first, t^, second temporal fissure. (t% is generally bridged, 
and so interrupted. ) 



ANATOMY. 



19 



In these diagrams only the important snlci are given ; 
these vary somewhat in different brains ; the convolu- 
tions between these snlci are subdivided by secondary 
sulci, whose arrangement is less constant. Occasion- 
ally one of the principal sulci may be bridged over by 
a convolution, causing an apparent irregularity. 




Fig. 2. — View of the brain from above. (Ecker.) 
Lettering same as in Fig. 1. 



From the cortex, medullary nerve-fibers pass through 
the white substance, the centrum ovale, converging to- 
ward the basal ganglia — corona radiata. They con- 
verge from all parts toward a tract of white substance 



20 



DISEASES OF TEE BRAIN. 



which separates these basal ganglia from each other — 
the internal capsule. 

This capsule is one of the regions whose physiology 
is best known, whose lesion gives the most definite 
and permanent symptoms. 



ra 



fa-A-, 



ra 



t3 




Fig. 8. — View of the brain from below. (Ecker.) 

F u gyrus rectus, the prolongation of the first frontal convolution ; F 9 , middle, 
F 3 , lower frontal convolution ; / 4 , sulcus olfactorius ; / 6 , sulcus orbitalis ; T t , 
second, or middle, T 3 , third, or lower temporal convolution ; T t , gyrus occipito- 
temporalis lateralis (lobulus fusiformis), T 6 , gyrus occipito-temporalis medialis 
(lobulus lingualis) ; t 2 , middle, t 3 , lower temporal fissure ; r 4 , sulcus occipito-tem- 
poralis inferior ; po, fissura parieto-occipitalis ; oc, fissura calcarina ; If, gyrus 
hippocampi; V, gyrus uncinatus; Ch, chiasma ; cc, corpora albicantia; EK, 
pedunculi cerebri ; C, corpus callosum. 




Fig. 4. — View of the medial surface of the right hemisphere. (Ecker.) 

CC, corpus callosum, cut through the middle ; Gf, gyrus fornicatus, IT, gyrus 
hippocampi, h, sulcus hippocampi, U, gyrus uncinatus ; cm, sulcus calloso-margi- 
nalis, Fi, first frontal convolution, its medial side ; c, end of sulcus centralis, A, 
anterior, B, posterior central convolution ; Oz, cuneus ; P', precuneus ; po, fissura 
parieto-occipitalis ; o, sulcus occipitalis transversus; oc, fissura calcarina; oo\ 
upper, oc", lower branch ; D, gyrus descendens ; T A , gyrus occipito-temporalis 
lateralis ; T 5 , gyrus occipito-temporalis medialis (lobulus lingualis) ; around the 
central fissure is a quadrilateral lobule, A, B, called the paracentral lobule. 



The accompanying representation, an outline from 
a photograph by Bitot, will give a sufficiently clear idea 
of the more important divisions. 

The caudate nucleus and the outer or third member 
of the lenticular nucleus receive few fibers from the co- 
rona radiata, nearly all of whose fibers pass into the in- 
ternal capsule. Fine bundles of white fibers pass from 
the lenticular nucleus into the internal capsule, and 
seem to pass on to the pyramidal tract. From the 
caudate nucleus many bundles of fibers pass into the 
anterior limb of the internal capsule ; others cross this 
and enter the lenticular nucleus. 



22 



DISEASES OF THE BRAIK 



The fibers which have been described as entering the 
internal capsnle are destined in part for the basis of 
the cms ; the remainder are lost in the different parts 
of the optic thalamus, and in the tegmentum cruris, 
some reaching the cerebellum. 




Fig. 5. — Horizontal section of the brain. 
ccl, corpus callosum ; en, caudate nucleus ; fv, fifth ventricle ; cl, claustrum ; i, 
island' of Eeil ; cf, crura of the fornix, which, turning upon themselves, form the 
corpora albicantia ; ee, external capsule ; tv, third ventricle ; th, optic thalamus ; 
cge, external corpus geniculatum ; era', the lower part of caudate nucleus ; pv, pul- 
vinar ; cq. corpora quadrigemina ; egi, internal corpus geniculatum ; i, n, in, the 
three divisions of lenticular nucleus (on the left only two divisions are seen) ; aic, 
hie, pic, the anterior limb, knee, and posterior limb of the internal capsule. 

The following diagrams, in some respects slightly 
modified from Wernicke, will help to an understand- 
ing of the course of the most important bundles of 
fibers, and the relations of the ganglia. 



ANATOMY. 



Charcot has shown that only a part of the fibers of 
the internal capsnle passes beyond the pons. The cap- 
sule is divided into an anterior and a posterior limb, 
the angle formed by the two being called the knee of 




Fig. 6. — Diagram of a perpendicular section of the brain, showing the internal 
capsule and its relations. 

gf, gyrus fornicatus ; cc, corpus callosum ; v, ventricle ; f, fornix ; nc, caudate 
nucleus ; tk, optic thalamus ; ci, internal capsule, upper (anterior) limb ; p, pedun- 
cle ; ci', internal capsule, lower (posterior) limb ; nc'-, lower part of caudate nucleus ; 
o, optic tract ; gh, gyrus hippocampus ; i, island of Eeil ; el, claustrum ; nl, len- 
ticular nucleus. 



the capsule. The fibers from the anterior limb pass 
through the inner portion of the basis cruris. When 
a lesion implicates only these, the descending degener- 



24 



DISEASES OF THE BRAIN. 



ation can be traced as far as the pons, but not beyond. 
That portion of the fibers of the basis which arises from 




Fig. 7. — Diagram of a horizontal section of the brain, showing the course of the 
peduncular fibers. 

ca, anterior commissure ; i, it, in, the three divisions of lenticular nucleus ; pi, 
pm, pe, the internal, middle, and external portions of the peduncular fibers passing 
below the optic thalamus. Other letters as in Fig. 5. 



ANATOMY. 



25 



the inner two thirds of the posterior limb passes 
throngh the middle third of the basis, and secondary- 
degeneration of these fibers can be followed throngh 
the pons and medulla into the pyramidal tracts of the 
cord. In Fig. 7 this portion of the internal capsule is 
shaded. Lesion of the outer third of the posterior 
limb of the capsule is followed by no descending de- 
generation; hence it is supposed that its fibers are 
centripetal, and they pass into the corona radiata of 
the occipital lobe. 




Fir. 8. — Diagram illustrating decussation of optic nerves in the chiasms, and 
the effect of lesions of portions of the optic tract, 
o, optic nerves ; ot, optic tracts ; eg, corpora geniculnta ; a, b, c, lesions in 
front, at side of chiasma, and on optic tract. 



26 



DISEASES OF TEE BRAIN. 



The decussation of the optic nerves at the chiasma 
is only partial. The diagram on page 25 may give an 
idea of the arrangement of the fibers. The fibers from 
the right optic tract pass to the right side of both reti- 
nas, the larger portion decussating with those of the 
opposite side ; and vice versa for those of the left optic 
tract. 




Fig. 9.— This is modified from Huguenin, to agree with Wernicke's description 
of the origin of the fibers of the optic tract. 
ag, anterior corpus quadrigeininum ; pu, pulvinar ; cpq, eras of posterior corpus 
quadrigeminum ; cgi, internal corpus geniculatum ; eye, external corpus genicu- 
latum ; cr, posterior fibers of the corona radiata, passing to the occipital lobe ; oe, 
external division of the optic tract, passing to the external corpus geniculatum, the 
pulvinar, and the anterior corpus quadrigeminum ; oi, the inner division of the 
optic tract, passing to the internal corpus geniculatum, and the posterior corpus 
quadrigeminum ; p, peduncular fibers ; p', the hemispherical bundle seen in trans- 
verse section of the crus cerebri; sn, substantia nigra; in, third nerve; m', its 
nucleus ; scp, superior cerebellar peduncle (red nucleus) ; plb, posterior longitu- 
dinal bundle ; as, aqueduct of Sylvius. 



ANATOMY. 27 

When an attempt is made to study the optic tract, 
tracing its fibers to their central origin, we meet some 
opposing statements made by different authors. Wer- 
nicke describes the optic tract, passing from the chiasma 
backward, as dividing into two portions — an external, 
which is much the larger, and a smaller internal ; the 
former can be traced to the external corpus genicula- 
tum, the posterior portion of the optic thalamus called 
the pulvinar, and the anterior corpus quadrigeminum ; 
the internal portion, he says, arises from the internal 
corpus geniculatum, and the posterior corpus quadri- 
geminum ; this division, he says (following v. Grudden), 
has no connection with the optic nerve. A bundle of 
fibers seems to pass directly from the corona radiata of 
the occipital lobe to the optic tract. 

The preceding diagram, Fig. 9, which follows Wer- 
nicke, is modified from Huguenin, and will aid in un- 
derstanding these divisions of the optic tract. 

The advantage of following the different bundles of 
fibers through the crura cerebri, pons, and medulla 
would be, to say the least, very doubtful. Huguenin, 
Wernicke, and Duval have given us studies of this re- 
gion. A few outline drawings or diagrams, with brief 
explanation, will serve to localize the important nerve- 
centers at different levels. 

The third nerve enters the crus near the anterior 
border of the pons, not far from the median line, form- 
ing the internal boundary of the pyramidal fibers; The 
nerve splits up into bundles of fibers which diverge, the 
inner bundles following a slightly waving course back- 
ward to the nucleus ; the outer bundles, forming a curve, 
pass through the outer edge of the cerebellar peduncu- 
lar fibers (the red nucleus), then converge to the nucle- 
us, which is situated on either side of the median line 
just anterior to the aqueduct of Sylvius. Anterior to 
the nucleus the nerve passes through the posterior lon- 
gitudinal fasciculus. The nucleus of the third is irregu- 
larly pear-shaped, the smaller end pointing forward, 



28 DISEASES OF THE BRAIN. 

lying near the median raphe. Curving around from 
the posterior longitudinal fasciculus can be seen the de- 
scending (motor) root of the fifth nerve. Posterior to 
these is the anterior corpus quadrigeminum, and ex- 
ternal to this the internal corpus geniculatum. 




Fig. 10. — Origin of third nerve. (After Wernicke.) 

as, aqueduct of Sylvius ; plb, posterior longitudinal bundle ; in, third nerve ; 
m', its nucleus ; p, basis of crus cerebri (foot of the peduncle) ; sn, substantia 
nigra ; cp, superior cerebellar peduncle (red nucleus) ; cgi, internal corpus genicu- 
latum ; acq, anterior corpus quadrigeminum ; v, descending (motor) root of tri- 
geminus. 



The fourth nerve enters the valve of Vieussens just 
behind the posterior corpus quadrigeminum, decus- 
sates in the valve, curves around the aqueduct of Syl- 
vius, and enters its nucleus, which is situated just be- 
hind (below) the nucleus of the third nerve in relatively 
the same position. 

Both the third and fourth nerves receive a few fibers, 
ascending from the sixth nerve, from the posterior lon- 
gitudinal fasciculi, which do not enter their nuclei. 

The nucleus of the third nerve receives fibers from 
the anterior corpus quadrigeminum, and probably simi- 
lar fibers pass to the nuclei of the fourth and sixth 
nerves. 



ANATOMY. 



29 



The sixth, and seventh nerves are closely connected 
at one point in their course. The sixth enters the an- 
terior aspect of the pons just at its junction with the 
medulla oblongata not far from the median line. It 
crosses the pons, changing its direction several times so 
that no one section can follow its whole course, and 
enters its nucleus just external to the eminentia teres 
near the median raphe on the floor of the fourth ven- 




FiG. 11 represents sections through the pons, so as to show on the left the 
seventh and sixth nerves, with their nuclei; on the right, the sixth and 
eighth nerves, half schematic. 

vn, seventh nerve ; vn', eminentia teres, where the seventh nerve turns down- 
ward ; vn", the proper nucleus of the seventh nerve ; vi, sixth nerve ; vi', the 
common nucleus of sixth and seventh ; vin, eighth nerve ; vm', its nucleus ; v, 
ascending root of the fifth nerve ; r, restiform hody ; so, the superior olive ; p, the 
peduncular fibers. 

tricle. This nucleus is also the origin of some of the 
fibers going to the seventh nerve, which enters the pons 
just anterior (forward) to the eighth, crosses diagonally 
in a gentle curve to this nucleus, from which it receives 
some fibers ; then it can be followed to the eminentia 
teres, where it turns downward ; it soon turns again to 
pass forward and outward, slightly downward, to its in- 
ferior nucleus. The fibers, in passing from the eminen- 
tia teres to this nucleus, divide and separate more or 



30 



DISEASES OF THE BRAIN. 



less widely from each other, and form a wide network 
rather than a compact bundle. The nucleus is com- 
posed of three or four groups of cells, in each section, 
which are each surrounded by separate bundles of 
fibers. Just outside the facial nerve, and anterior to 
its inferior nucleus, is the ascending root of the fifth 
nerve. 

From the nucleus of the sixth nerve thin bundles 
of fibers pass forward (upward) in the posterior longi- 
tudinal fasciculus to the third and fourth nerves. These 
communicating fibers decussate in their course quite 
near the point where they unite with the other fibers 
of the third and fourth nerves. 

The course of the eighth nerve is not as yet of so 




Fkj. 12. — Transverse section of the medulla on the right at a higher level than 
on the left. (After Wernicke.) 

P, the anterior pyramidal fibers ; 6>, the inferior olivary body ; Ic, the lateral 
column ; cr, the restiform body ; pc, the posterior columns ; /, longitudinal fibers ; 
c, central canal ; Va, ascending root of the fifth ; x, xi, xn, the corresponding 
:', xi', xii', their nuclei ; x", anterior vagus nucleus. 



ANATOMY. 



31 



much practical interest. It enters the pons just behind 
(below) the seventh, and divides into three bundles, 
which are distributed to separate nuclei. It is scarcely 
necessary to give the particulars of its deep origin. 




Fig. 13. — Schematic view of the relative situations of the nuclei in the medulla. 
(After Erb.) 

v-xn, the nerves or their nuclei ; 1, middle, 2, superior, 3, inferior cerebellar 
peduncle; 4, restiform body ; 5, eminentia teres ; 6, acoustic fibers ; V, ala cinerea. 



The relations and origins of the nerves of the me- 
dulla oblongata can be easily learned by a study of the 
accompanying figures (12 and 13), and it is scarcely 
necessary to give more detailed descriptions. 

The distribution of the blood-vessels in the brain 
has been studied especially by Duret. The results ob- 
tained are of much practical value. The circle of Wil- 



32 DISEASES OF TEE BRAIK 

lis at the base of the brain furnishes rather free com- 
munication between the carotids and the vertebrals of 
the same side, and between the arteries at the posterior 
part of the brain on opposite sides, unless there are 
anomalies in the size of the arteries. Anteriorly, the 
only communication between the two carotids is the 
anterior communicating artery. 

The nutrient arteries for the corpus striatum and 
optic thalamus arise from the first few centimetres of 
the anterior, middle, and posterior cerebral arteries ; 
those from the posterior cerebral are distributed to the 
optic thalamus, the others to the caudate and lenticular 
nuclei. These nutrient arteries arise, then, from a posi- 
tion where they are the more likely to feel any increase 
of blood-pressure ; anastomoses between the secondary 
arteries supplying these regions are very unusual. 

The convolutions are supplied with blood-vessels 
from the pia mater covering them. The anastomoses 
between the different arterial systems in the pia mater 
are very few and unimportant. The arterioles, after 
entering the gray substance, quickly subdivide into the 
minutest branches ; these anastomose freely with each 
other. The vessels for the subjacent white substance 
pass through the cortical layers, giving off only a few 
branches, and finally subdivide in the medullary sub- 
stance into elongated meshes. There are no important 
anastomoses between the arteries of the convolutions 
and those of the large ganglia at the base, even where 
the two come very near together, as in the corpus stri- 
atum opposite the insula. 

The veins anastomose more freely, and are so dis- 
posed with reference to the arteries of the convolutions 
that the blood is delayed, especially in the arterioles in 
the gray substance, and the nerve-cells are continuous- 
ly bathed in arterial blood. 

As the arteries branch at nearly right angles, and 
subdivide rapidly into very small vessels, the blood- 
pressure is diminished ; but the absence of communi- 



PHYSIOLOGY. 33 

cations between the larger branches does not allow of 
the removal of pressure from weakened arteries. 

Most of the first and second frontal convolutions, 
and the convolutions in the median fissure as far back 
as the termination of the sulcus calloso-marginalis, are 
supplied by the anterior cerebral arteries. The third 
frontal convolution, the anterior central and posterior 
central, and very nearly all the parietal and the upper 
part of the temporal lobes and the insula, are supplied 
by the middle cerebral. The lower portion of the tem- 
poral and the occipital lobes are supplied by the pos- 
terior cerebral artery. 

One of these arteries, or any of their branches, may 
be obstructed mechanically, or may be subject to tem- 
porary reflex spasms, so as to interfere with the proper 
flow of blood. Hyperemia may also affect any one dis- 
trict, leaving the others nearly unaffected. 

PHYSIOLOGY. 

Fritsch and Hitzig (1870) first called attention to the 
irritability of certain districts of the cerebral cortex as 
suggesting the localization of motor functions in sepa- 
rate and distinct regions of the brain. Ferrier soon 
after (1873) published observations made in the same 
direction, and has since greatly extended our knowl- 
edge. During the last ten years the literature of the 
subject has increased wonderfully. 

The region of the cortex immediately anterior and 
posterior to the fissure of Rolando has been found to 
be excitable ; an irritation applied to this region causes 
motion in the voluntary muscles, according to the lo- 
cality of the irritation. Other regions may be excitable, 
and probably are, but the above central region is the 
one which seems to act most directly upon the limbs. 
When motion is produced by irritation of other regions, 
it is probably indirect. Other regions than these may, 
when irritated, cause various sensations or give rise to 
mental actions ; but these are not revealed to us by 



34 DISEASES OF THE BRAIK 

motor phenomena. A careful study of Ferrier's plate, 
with the motor centers marked on Ecker's diagram of 
the convolutions, will be all that is needed to fix these 
centers in the mind. 




F IG . 14. — Location of motor and other centers in the cerebral cortex. (Fierier.) 

1, on the upper or superior parietal lobule center for the opposite leg ; 2, 3, 4, 
around the upper end of central fissure, centers for opposite leg, arm, and 
trunk ; 5, centers for motion of opposite arm and hand forward ; a, J, c, d, on the 
posterior central convolution, centers for motions of fingers and wrist of opposite 
hand ; 6, supination and flexion of the opposite forearm ; 7, 8, 9, 10, 11, on the 
anterior central convolution and around the base of central fissure, motions of 
mouth, lips, and tongue (9, 10 are called oro-lingual centers by Ferrier) ; 12, eleva- 
tion of eyelids, dilatation of pupils, conjugate deviation of eyes, and turning of 
head to opposite side ; 13, 13', centers which seem to have relation to vision and 
cause motions of the eyes ; 14, centers which seem to be concerned with hearing, 
and give rise to motions expressive of attention. 

The views as to the sensory centers are still unset- 
tled. It is much more difficult to locate these ; and, 
indeed, the facts as yet known rather tend to show that 



PHYSIOLOGY. 35 

the centers for different sensations are much less clearly 
denned than those for motion. 

Ferrier locates the centers for sensation in the pari- 
etotemporal region ; sight in the snpra-marginal and 
angnlar convolutions (13, 13') ; hearing in the superior 



Fig. 15. — Location of motor and other centers in the cerebral cortex. (Ferrier.) 
Lettering same as Fig. 14. 

or first temporal convolution (14) ; taste and smell in 
the lower extremity of the temporo- sphenoidal lobe — 
region of the subiculum cornu Ammonis ; tactile sensa- 
tion in the region of the hippocampus. The centers for 
sight and hearing are probably correctly located, but 
there are also centers for sight in the occipital lobe 



36 DISEASES OF THE BRAIN. 

quite as important as those in the angular and supra- 
marginal convolutions. There is some uncertainty as 
to the other sensory centers. 

Petrina is of opinion that the faculty of sensation is 
more generally diffused, and that at least the fibers for 
tactile sensation follow the motor fibers to the motor 
centers, and terminate there in sensory cells. Thus he 
regards each motor center as also in some degree sen- 
sory. 

The location of the centers for tactile sensation must 
be considered as undetermined. It is, however, settled 
that the sensory fibers pass through the posterior third 
of the posterior limb of the internal capsule, through 
the outer part of the cerebral peduncle, the lateral part 
of the pons Varolii near the floor of the fourth ventricle, 
to the sensory region of the cord. 

The fibers of the corona radiata may be classed as 
motor or sensory, according to the portion of the cortex 
with which they are connected. Lesion of the white 
fibers passing from the motor centers of the cortex to 
the internal capsule causes serious disturbance of mo- 
tion ; if extensive, a permanent hemiplegia of the oppo- 
site side will be produced ; if limited, they may give 
rise to monoplegias, just as limited lesions of the cortical 
motor zone. 

Following these fibers into the internal capsule, 
Franck and Pitres found : 1. Quite in front the fibers 
which, on irritation, cause motion in the face and eye- 
lids on the opposite side. 2. Next behind, the fibers for 
the anterior limbs on the opposite side. 3. A bundle 
of fibers which move both limbs on the opposite side. 
4. A very small bundle for the opposite hind limb. 5. 
In the posterior part of the caudate nucleus those which 
cause elevation of the opposite ear. 

These experiments were made upon animals ; clini- 
cal observations and post-mortem examinations must 
finally show how nearly the same order is followed in 
man. 



GENERAL SYMPTOMATOLOGY. Zl 

The functions of the ganglia at the base are not yet 
well determined. We know nothing in regard to the 
functions of the caudate and lenticular nucleus ; they 
do not seem to have any direct control over either mo- 
tion or sensation, which has as yet been discovered. 

The functions of the optic thalamus are still a subject 
for investigation and discussion. Nothnagel, from ex- 
periments on animals, concludes that motor impulses, 
which are excited, or depend upon peripheral sensory 
impressions, take their origin in the optic thalami. 

Wernicke's conclusions agree very nearly with this 
view. "They serve, 1, for acquiring consciousness of 
motions through 'muscular sense' or innervation's 
sense ; 2, for the involuntary adaptation of our motions 
to external relations by means of the reflex mechan- 
ism which they contain ; 3, as a way for certain sensory 
tracts, which, according to Meynert, serve for trans- 
mission of muscular or innervation's sense." 

The posterior portion of the optic thalamus, the 
pulvinar, forms a part of the visual centers ; it stands 
in intimate relations with the corresponding halves of 
both retinas, as is shown by the symptoms in cases 
where it is destroyed. Exactly how these relations 
are maintained is not yet definitely known. 

The physiology of the pons, medulla, and neighbor- 
ing parts can be inferred from the anatomical descrip- 
tions given above, or will be mentioned more conven- 
iently in connection with the symptoms due to their 
lesion in the following sections. 

GENERAL SYMPTOMATOLOGY. 

Lesions affecting the brain may be divided into two 
classes, destructive and irritative. These may act only 
upon the nerve-fibers which they immediately affect ; 
or they may exert an influence at a distance, which 
may be different in its nature from their immediate in- 
fluence. A haemorrhage will destroy nerve-fibers, which 



38 DISEASES OF TEE BRAIN. 

are torn across ; it will also, if of sufficient size, inter- 
fere with the function of others by compressing them, 
and it may give rise to symptoms of irritation. A 
tumor may irritate certain fibers, and, by compression, 
prevent the action of others, or it may destroy those 
among which it grows, and irritate others at a dis- 
tance. As a rule, a lesion which occurs suddenly, as a 
haemorrhage, will give rise to more symptoms depend- 
ing upon interference with distant regions than those 
lesions which slowly increase in size. It may be neces- 
sary, then, in forming an opinion as to the seat of a 
lesion, to wait until the commotion produced by the 
first shock of the disturbance has subsided and the 
remote symptoms have disappeared. 

Destruction of the motor centers, or of the white 
fibers of the corona radiata underlying these centers, 
is revealed by paralysis of the limbs or muscles over 
which they preside. Irritation of these parts gives rise 
to spasm of those muscles. It may happen that there 
is first an irritation due to the destruction of fibers, 
shown by a spasm : then follows the paralysis depend- 
ent upon the permanent lesion. If the irritation is 
very strong, it not only excites to activity the center 
on which it first acts, but neighboring centers, and per- 
haps the whole motor area of both hemispheres, may be 
thrown into commotion ; then general convulsions will 
result. 

By a careful study of the seat of the paralysis or 
convulsion, and a comparison of these with the motor 
centers, a reasonably accurate conclusion as to the seat 
of a cortical lesion may be formed. Spasms confined 
to one limb are much more clearly diagnostic of corti- 
cal lesion than paralysis. When convulsions are gen- 
eral, the diagnosis is less certain ; but, by watching the 
commencement of the attack, noting that invariably 
the same limb is first affected each time, and that the 
convulsions follow the same course, a correct diagnosis 
may often be made. 



GENERAL SYMPTOMATOLOGY. 39 

The caudate nucleus and the lenticular ganglion 
may be nearly or quite destroyed without any disturb- 
ance of motion or sensation. Generally, however, es- 
pecially if the destruction is produced by a hsemor- 
rhage, there is more or less compression of neighboring 
parts, the internal capsule is thereby disturbed, and 
symptoms result therefrom. Often, also, a portion of 
the capsule is destroyed, and then the symptoms are 
permanent. If the destruction is limited to the gray 
ganglia, as the clot is absorbed the pressure upon the 
capsule is removed, and the symptoms may entirely 
disappear. 

The optic thalamus may be partially destroyed with- 
out special symptoms; those which occur seemingly 
depend upon pressure or implication of neighboring 
parts. At other times there are disturbances of sensa- 
tion which seem to arise directly from the lesion of the 
thalamus. Injuries to the optic thalamus may cause 
more or less disturbance of vision. When the anterior 
or middle portions are injured, this disturbance, if 
present, is temporary ; if the posterior part, the pul- 
vinar, is injured, the loss of vision is permanent, and 
generally affects only one half the visual field — hemi- 
anopsia. 

There is a small region, carrefour sensitif, lying 
external to the pulvinar, which serves as the course for 
sensory fibers. Lesion of this region will give rise to 
hemianesthesia ; and when there is disease of the optic 
thalamus or pulvinar, this region would very likely be 
disturbed. 

A peculiar motor disturbance is associated with 
injury of the posterior and outer part of the optic 
thalamus, and perhaps adjacent parts, though some 
observations seem to show that lesion of the thalamus 
alone is sufficient to produce the phenomena. The par- 
tially or entirely paralyzed limbs are in a state of un- 
rest ; they keep up a constant motion, which may be sim- 
ply a tremor, or a slow, irregular motion in all directions 



40 DISEASES OF TEE BRAIK 

without co-ordination or rhythm, sometimes resembling 
chorea, sometimes peculiar and unlike any other motor 
phenomena. This has been called athetosis, or post- 
hemiplegic chorea. 

The internal capsule is the most important part of 
the base of the brain, so far as relates to the symptoms 
arising from its destruction. 

When the anterior limb of the internal capsule is 
destroyed, secondary degeneration affects only the in- 
ternal segment of the base of the eras, and this degen- 
eration can not be followed beyond the pons. When 
the anterior two thirds of the posterior limb are de- 
stroyed, there is descending degeneration, which can be 
followed through the middle segment of the eras, the 
pons, medulla, and anterior pyramids, where it crosses 
to the opposite side of the cord, excepting a small por- 
tion, the anterior pyramidal fibers, which pass down- 
ward on the same side. When the outer third of the 
posterior limb is destroyed, there is no descending de- 
generation. Hence we conclude that the most, if not 
all, of the motor fibers for the trunk and limbs from the 
motor area of the brain pass through the anterior two 
thirds of the posterior limb of the internal capsule, and 
follow the course taken by the descending degeneration. 

When the anterior limb of the internal capsule is 
destroyed, there is no paralysis of the limbs ; the facial 
nerve may be paralyzed. 

When the anterior two thirds of the posterior limb 
are destroyed (or pressed upon so as to interfere with 
function), there is always paralysis of motion in the op- 
posite side of the body. This paralysis is permanent, 
and is followed by late contraction, due to secondary 
degeneration of the pyramidal tract. 

When the posterior third of the posterior limb is 
destroyed, there is anaesthesia of the opposite side ; 
Charcot calls this cerebral hemianesthesia, and says it 
is a faithful reproduction of the characteristics of hys- 
terical hemianesthesia ; the insensibility extends to the 



GENERAL SYMPTOMATOLOGY. 41 

profound parts, muscles, mucous membranes ; it in- 
volves also the sensory apparatus, the senses of taste 
and hearing, of smell and sight. The sight is lost by a 
concentric narrowing of the field of vision ; the percep- 
tion of colors is lost — first green, then red, orange, yel- 
low, and blue, until everything has a grayish hue. 

When disease of one hemisphere causes amblyopia 
or amaurosis, the disturbance of vision is observed in 
the opposite eye ; a slight defect may also be discov- 
ered in the corresponding eye if carefully sought, pro- 
vided the intelligence of the patient is not too much 
disturbed. The lesion is then situated in the posterior 
third of the posterior limb of the inner capsule, or in 
some portion of the cortex which is not yet exactly 
located, but which probably corresponds to Ferrier's 
centers (13, 13') in the angular gyrus, or it may be in 
some portion of the occipital lobe. 

Many times the loss of vision affects only one lateral 
half of the visual field. This is called hemiopia, in 
speaking of the loss of power in the retina, or more 
usually hemianopsia, as referring to the visual field. 

When there is double temporal hemianopsia — the 
loss of sight affecting the temporal half of both visual 
fields — the lesion must be in the chiasma, probably near 
its anterior border, at a, Fig. 8. 

When the nasal half of the visual field is lost — nasal 
hemianopsia — the lesion must be on the corresponding 
side of the chiasma, 5, Fig. 8 ; both sides are rarely 
thus affected. If there is amblyopia or amaurosis of 
one eye and nasal hemianopsia of the other eye, the 
lesion must be on the side of the chiasma correspond- 
ing with the amblyopic eye, and penetrate deep enough 
to affect the decussating fibers. 

When there is loss of vision for corresponding lat- 
eral halves of both visual fields, the defect is called lat- 
eral homonymous hemianopsia. This may be caused 
by lesion of the opposite optic tract (<?, Fig. 8), of 
the pulvinar, of the occipital lobe, or possibly of the 



42 DISEASES OF THE BRAIN. 

angular gyrus, or of the fibers passing from the pulvi- 
nar to the centers of vision. If there is no reaction of 
the pupil when light falls upon the affected half of the 
retina, the lesion must be in the optic tract or the ante- 
rior corpus quadrigeminuni — i. e., in right lateral he- 
mianopsia the left optic tract would be affected. 

If the pupil reacts when light falls upon the affected 
half of the retina, the lesion is either in the pulvinar, 
in the corona radiata, or the cortex. When the pul- 
vinar is the seat of a haemorrhage, there may be other 
symptoms of apoplexy, motor or sensory; these will 
disappear in a short time, but the hemianopsia will be 
permanent. There may be photopsia. 

When the corona radiata leading to the centers of 
vision is the seat of haemorrhage, the hemianopsia will 
at first be complete, but soon the vision will be partially 
restored ; there will be other apoplectic symptoms. If 
the loss of sight is caused by tumor, it will come on 
gradually, and will be accompanied by other symptoms 
— paralysis of cranial nerves, etc. — showing the nature 
and seat of the lesion. Photopsia may be present. 

When the cortical centers of vision are affected, there 
will be no photopsia ; the hemianopsia may be complete 
or only partial ; there may be loss of perception of color 
in one half of the visual field, with power to perceive 
white. There will be no other paralysis except vision. 

Charcot and his followers claim that lesion of the 
hemispheres is more frequently followed by amblyopia, 
contraction of the field of vision, and that hemianopsia 
is rare. Fere thinks the lesion causing hemianopsia 
must be situated between the angular gyrus and the 
fissure of Rolando, or in the medullary fibers leading 
from that region. We do not yet know why in one 
case there is hemianopsia and in another amblyopia. 

When the lesion is situated below the internal cap- 
sule, so that the cms cerebri, or parts below, are inrpli- 
ca'fed, the cranial nerves may be affected on the same 
side with the lesion. The symptoms may then be in 



GENERAL SYMPTOMATOLOGY. 43 

part on the same side, in those nerves directly affected ; 
in part on the opposite side, for the nerves arising below 
the seat of the disease. This gives a crossed or alter- 
nate paralysis. A comparison of the symptoms with 
the physiology and anatomy of this part of the mesen- 
cephalon will lead to as correct a diagnosis of the loca- 
tion of the lesion as can be made. 

Lesions of the anterior corpora quadrigemina are 
attended with partial or total loss of vision. If the 
lesion is unilateral, the loss of vision is also unilateral. 
Opinions differ as to whether there is simple unilateral 
amaurosis or lateral hemianopsia. 

Lesions of the posterior corpora quadrigemina are 
associated with inco-ordination, which JSTothnagel says 
is like that found in lesion of the cerebellum, and which 
is possibly dependent upon a coincident lesion of the 
superior cerebellar peduncle. 

These symptoms alone would not be sufficient to 
locate the lesion in the corpora quadrigemina. There 
will often be found .other symptoms due to extension 
of the lesion to neighboring parts. 

The third and fourth nerves, with their nuclei, lie 
just below the corpora quadrigemina, and may be im- 
plicated ; then there would be partial or entire paraly- 
sis of these nerves. The motor and sensory tracts pass 
through the crura cerebri, and may be implicated, giv- 
ing rise to corresponding symptoms. 

The third nerve supplies many different muscles. Its 
most anterior fibers are for accommodation ; just behind 
these are the fibers which innervate the sphincter of the 
iris ; then are arranged the fibers for the internal rectus, 
the superior rectus, the levator palpebrae superioris, the 
inferior rectus, and the inferior oblique.* When the 

* Kahler and Pick suggest that the posterior bundles supply the le- 
vator palpebral, rectus superior, and obliquus inferior — muscles which 
are employed together in looking upward; that the posterior median 
bundles innervate the internal rectus and the inferior rectus ; the an- 
terior, the pupillary, and accommodation muscles. 



44 DISEASES OF THE BRAIN. 

nucleus or the nerve in its course through the peduncle 
is affected, the symptoms will guide to a diagnosis of 
the seat of the disease. Kahler and Pick say a disas- 
sociated, partial paralysis of the oculo-motor nerve 
points primarily to a lesion of the territory through 
which the roots of this nerve run. 

Most significant for lesion of the cerebral pedun- 
cles is the alternate paralysis of the motor-oculi nerve. 
The limbs and face, perhaps also the tongue, are para- 
lyzed on one side, opposite to the lesion ; the ocular 
muscles are paralyzed on the other side, the same side 
with the lesion. Great disturbance of sensation would 
indicate that the outer portion of the crus was affected. 

In case of disease of the pons Varolii a few symp- 
toms are important ; among these, alternate paralysis, 
the limbs affected, as to motion and sensation, on the 
side opposite the lesion, the cranial nerves on the same 
side with the lesion ; whether the facial, the fifth, the 
sixth, are all or only in part paralyzed on the side op- 
posite the limbs, depends upon the height at which the 
disease is situated. If there is thus alternate paralysis, 
the disease is almost sure to be in the pons, sometimes 
it may be in the medulla oblongata. 

A conjugate deviation of the eyes to one side is diag- 
nostic of lesion of the pons, when, in case of paralysis, 
the eyes are turned toward the hemiplegic side ; in case 
of spasm, away from that side. This symptom points 
to the vicinity of the nucleus of the sixth nerve as the 
locality of the lesion. 

Conjugate deviation of the eyes is found, associated 
with deviation of the head to the same side as the eyes, 
in cases of haemorrhage into the hemispheres. Then 
the symptom is of only short duration ; in a few hours 
or a few days the motions of the eyes and head become 
free. Under these circumstances it is of little value in 
locating the lesion; it may accompany superficial le- 
sions, or those which involve the cerebral substance, 
becoming more frequent as the lesion is situated nearer 



GENERAL SYMPTOMATOLOGY. 45 

the corpus striatum and the fibers radiating from the 
cerebral peduncle. The deviation is away from the 
paralyzed side, toward the affected hemisphere ; when 
there are convulsions, the deviation is toward the side 
convulsed. 

When conjugate deviation of the eyes occurs in dis- 
ease of the pons, it is usually independent of any de- 
viation of the head, and is persistent. 

In examining the eyes, it is necessary to examine 
them together, and each one separately. In paralysis 
due to disease of the pons, the abducens on the same 
side with the lesion is paralyzed alternately with the 
limbs. The internal rectus then draws the affected eye 
toward the opposite side. The internal rectus of the 
other eye, on account of the union of the sixth nucleus 
with the third nerve, being paralyzed, so far as acting 
in harmony with the opposite abducens, allows that 
eye to be drawn outward by its external rectus. As 
the fibers of the third nerve, which control the direc- 
tion of the eyes for near vision, are not paralyzed, 
being independent of the sixth nerve, both eyes will 
turn inward naturally when an object is slowly ap- 
proached to the eyes. When examined separately, the 
eye whose abducens is paralyzed can not be turned 
outward beyond the median line ; the other eye can be 
turned inward, though, it may be, only with consid- 
erable effort. In this separate examination of each eye 
some nystagmus may be noticed. 

When the abducens alone of the ocular nerves is 
paralyzed, the pons must be the seat of the disease, 
unless other symptoms show that the lesion is pe- 
ripheral. 

When only one pupil is persistently contracted, 
lesion of the pons on the same side is indicated. 

When speech is affected, it is in the form of anar- 
thria. 

The sensory fibers are said to pass through the lat- 
eral portions of the pons, and great or total loss of sen- 



46 DISEASES OF THE BRAIK 

sation in disease of the pons would point to that por- 
tion as its seat. 

Compulsory motions and ataxia would be rather 
indicative of lesion of the cerebellar peduncle than of 
the pons, though Penzoldt noticed compulsory motion 
backward when the middle portion of the pons was 
affected. 

When the cerebellum is the seat of a tumor, many 
symptoms will be caused by pressure upon neighboring 
parts ; also in case of haemorrhage the earlier symptoms 
may be in part due to the effects of influences acting 
upon other regions. In disease of the cerebellum, vom- 
iting is a very common symptom ; optic neuritis is fre- 
quent ; the ventricles may be distended with serum. 
The most characteristic symptom is motor disturbance, 
a general weakness and a disturbance of co-ordination, 
with vertigo and uncertainty of gait. This disturbance 
of gait is found only when the vermiform process or 
the middle lobe of the cerebellum is affected. When 
the middle lobe is diseased, there is likely to be pria- 
pism. The cerebellar hemispheres may be extensively 
diseased without causing characteristic symptoms. 

The symptoms at a distance due to pressure, etc., 
will generally be a great aid to diagnosis, and without 
these it may be impossible to locate the disease. 

The symptoms caused by lesion of the nuclei in the 
medulla oblongata will be described under Bulbar Pa- 
ralysis. 

DISTURBANCES OF SPEECH. 

Speech may be interfered with in several ways : 1. 
The power of transforming thought into words may be 
lost {amnesic aphasia) ; the patient may yet under- 
stand what is said and be able to read. The loss of 
speech may be absolute, or, as is more common, the 
patient may retain the power of speaking certain words 
or phrases ; these expressions are usually "yes" and 
"no," which may be used correctly, but quite as often 



DISTURBANCES OF SPEECH. 47 

incorrectly ; certain expressions which are of the natnre 
of exclamations and oaths may be retained. The ex- 
tent to which speech is affected varies greatly ; some- 
times patients can repeat a sentence spoken in their 
hearing, sometimes can read aloud, yet immediately 
after are unable to say the same words; sometimes 
they can spontaneously speak a part of a sentence, or 
they may occasionally be at a loss for a word, and rec- 
ognize it when suggested. Sometimes only one class 
of words is lost, as nouns, or words expressing relations 
or adjectives. 

When the loss of the faculty of recollecting words 
is marked, there is also a loss in the power of express- 
ing thought by gestures (amimia), and the patient can 
not write, even if the motions of the hand would permit 
writing (agraphia). They are unable to write with the 
left hand. In attempting to write, sometimes only lines 
are made, sometimes separate letters, but not words ; 
or words may be written, but not to form sentences. 

2. The patient may have the power to change 
thought into words, but the connection between the 
center where this is done and the vocal organs is inter- 
rupted, and the patient can not express himself. This 
is called ataxic aphasia, or anarthria ; the lesion may 
be at any point between the speech-centers and the 
vocal organs. When, however, the nuclei of the nerves 
in the medulla are diseased, peculiar difficulties of ut- 
terance are produced which are not properly included 
under this title, and which will be considered in con- 
nection with bulbar paralysis. 

Under the name dysarthria may be included cer- 
tain disturbances of speech, as stuttering, explosive 
speech, scanning speech, trembling speech, etc. 

When there is anarthria, ataxic aphasia, the patient 
is unable (according to the degree of loss of power) not 
only to speak, biit he is also unable to read ; he may, 
however, be able to express himself by gestures and by 
writing. 



48 DISEASES OF TEE BRAIN. 

3. A peculiar disturbance of the faculty of speech 
has been attracting attention lately. The patient is 
able to hear sounds or see objects ; he is able to origi- 
nate thought and give expression to his thought in 
words more or less appropriate ; but words spoken con- 
vey to him no ideas, or words written are not recog- 
nized as words. There is, as named by Kussmaul, 
"word-deafness" or "word-blindness." The patient 
may also lose the power of recognizing tunes, or of 
reading musical notes. 

It is rare to find word-deafness or word-blindness 
without other affection of speech. 

4. Kussmaul gives two other divisions of speech dis- 
turbance which are closely allied, paraphasia, and 
agrammatism or aJcataphasia. The former is " the 
inability to properly connect word-images and the cor- 
responding conceptions, so that, instead of the ones 
corresponding to the sense, misplaced or entirely in- 
comprehensible word-images present themselves " ; the 
latter is "the inability to form words grammatically 
and to arrange them in sentences syntactically." 

These peculiar defects of speech may accompany 
ordinary amnesic or ataxic aphasia ; they rarely occur 
alone. It may be convenient to retain the term para- 
phasia, which is the more frequent of these two forms 
of disturbance. 

5. There may be entire loss both of power to com- 
prehend what is said and of the power of expressing 
thought. 

The lesions which cause these different forms of dis- 
turbance of speech are situated in the vicinity of the 
posterior part of the third frontal convolution, the 
island of Reil, and the first temporal convolution, or 
in the white medullary substance just below these parts, 
or in the course of the motor fibers leading to the vocal 
organs. The amnesic aphasia depends on lesion of the 
posterior part of the third frontal convolution and the 
island of Reil near that spot, or the white substance 



DISTURBANCES OF SPEECH. 49 

immediately below ; anarthria depends upon interrup- 
tion of the centrifugal fibers passing to the vocal organs ; 
word-deafness and word-blindness occur when there is 
lesion of certain portions of the auditory or visual cen- 
ters. The exact seat of these changes is not yet well 
determined. Paraphasia is found in lesion of the 
island of Reil, the adjacent parts of the first temporal 
convolution, or the commissural white fibers immedi- 
ately below. 

In all forms of speech disturbance the lesion is found, 
in the great majority of cases, on the left side, and is 
associated generally with more or less fully developed 
right hemiplegia. In left-handed persons the lesion is 
usually on the right ; there is left hemiplegia. In a 
few cases this rule is not observed. 

When the centrifugal fibers are destroyed near the 
base of the brain, in the cerebral peduncles, pons, or 
medulla, there may be anarthria with either right or 
left hemiplegia ; such cases do not follow the above 
rule, and it may be that in some of the anomalous cases 
the distinction between true aphasia and ataxic aphasia 
or anarthria has not been sufficiently noticed. 



CHAPTER III. 

DISEASES OF THE MEMBRANES. 

Virchow, Das Haematom der Dura Mater. Verhandl. d. phys. 
med. Gesell. in Wurzb., 1857, vii, p. 134.— Hdguenin, in-Ziems- 
sen's Cyclopaedia, vol. xii. — G-riesinger, W., Haematom der Dura 
Mater. Arch. d. Heilkunde, 3. Bd., 1. H.— Kremiansky, Jacob, 
Ueber die Pachymeningitis interna haemorrhagica bei Menschen 
und Hunden. Virch. Arch., 42, 1868, pp. 129 and 321.— Dujar- 
din Beaumetz, A Lecture on the Treatment of Meningitis. New 
York Med. Journal, Aug. 11, 1883, p. 141.— Bertalot, H., Ueber 
Meningitis tuberculosa bei Kindern. Jahrbuch f. Kinderheil- 
Jcunde, ix, 1876, p. 227. — Seitz, Johannes, Die Meningitis tuber- 
culosa der Erwachsenen, Berlin, 1874. —Dawson, Y., Tubercular 
Meningitis in an Infant ; Death ; Necropsy ; Remarks. London 
Lancet, April 12, 1884, p. 660. 

PACHYMENINGITIS. 

Inflammation of the dura mater is not very common 
as an independent disease. The dura mater is composed 
of two lamellae which are loosely united with each other ; 
either of these may be the seat of disease ; hence arise 
external and internal pachymeningitis. 

EXTERNAL PACHYMENINGITIS 

is caused by disease of adjacent bony structures or by 
injuries. The symptoms are so combined with those 
arising from the primary affection, and the indications 
for treatment depend upon the nature of that affection 
to such a degree, that it is not necessary to delay longer 
on this variety of the disease. 



PACHYMENINGITIS. 51 

INTERNAL HEMORRHAGIC PACHYMENINGITIS. 

There are two different views as to the origin of 
hsemorrhagic pachymeningitis : one proposed by Vir- 
chow and generally adopted, according to which there 
is first a congestion of the dura mater, which gives rise 
to a thin membrane on its inner surface ; under tMs 
membrane occur haemorrhages ; the clot becomes or- 
ganized and forms a membrane of greater or less thick- 
ness, under which more blood is poured out, and this 
process may be frequently repeated. 

Huguenin states that he has not been able to dis- 
cover any initial inflammation of the dura mater, nor 
any dilatation of the middle meningeal artery. He 
says the first stage is simply an extravasation of blood, 
which becomes organized, forming a false membrane, 
and from this arise new haemorrhages. The difference 
between Yirchow and Huguenin relates only to the 
first stage of the disease. 

The brain may be much compressed, and, as the 
affection occurs chiefly in patients suffering from other 
diseases, the changes due to those diseases will be 
found. 

JEtiology. — The larger proportion of patients are 
advanced in age ; many have been hard drinkers ; some- 
times an acute disease immediately precedes the menin- 
geal affection ; the insane, or those suffering from other 
cerebral disease, may be attacked. Huguenin finds a 
cause in cerebral atrophy, whether the result of old 
age, alcoholism, or other cerebral changes ; he also be- 
lieves the blood comes from the veins of the pia mater. 
Injuries have been sometimes the cause. 

Symptoms. — Many times the hsematoma gives rise 
to no characteristic symptoms. 

Headache is the most common symptom ; this may 
be severe, or there may simply be a sense of heaviness 
or pressure. Sometimes the patient has a sensation as 
if something moved back and forth in his head, which 



52 DISEASES OF TEE BRAIN. 

Griesinger refers to the sensation caused by a large 
cyst moving with the motion of the head. This is, 
however, felt under other circumstances where there 
can be no cyst, and therefore is not pathognomonic. 

When the haemorrhage first occurs, there will be the 
symptoms of meningeal haemorrhage, more or less fully 
marked ; the symptoms of cerebral compression, aboli- 
tion or dullness of intellect ; motor disturbance, irregu- 
lar spasmodic motions, contractures, or loss of power, 
sometimes paralysis ; slowness of pulse, sometimes with 
irregularity ; the opposite pupil more dilated, the cor- 
responding pupil contracted. 

These symptoms may be very marked if the haemor- 
rhage is large, and the paralysis may even be bilateral, 
though one side is affected first, the other later. 

The patient regains after some days his former con- 
dition of health, or may remain dull, drowsy, and 
paretic ; usually the headache persists. After a longer 
or shorter interval, another attack occurs. With the 
repetition of the phenomena the diagnosis becomes 
more certain. 

Diagnosis. — When the haemorrhage is insignificant, 
a correct diagnosis may be impossible ; when the haem- 
orrhage is large, the symptoms are those of meningeal 
haemorrhage, and it is only by waiting for the subse- 
quent course of the case to develop that a diagnosis can 
be made. 

Prognosis. — The disease is always serious and gen- 
erally fatal ; recovery may occur. Griesinger reports a 
case in which the haemorrhagic cyst was found nine 
years after the attack, the patient having recovered his 
health. Often, however, the disease with which the 
pachymeningitis is associated is one which renders re- 
covery hopeless. 

Treatment. — The treatment should have reference 
to preventing the haemorrhage, to favoring absorption. 
Quiet, rest, cold to the head without intermission, 
leeches behind the ears, and a light diet, may fulfill the 



INFLAMMATION OF TEE PI A MATER. 53 

first indication immediately after the acute attack. In 
the interval everything which would favor increase of 
blood-pressure should be avoided. Iodide of potas- 
sium and mercury in moderate amount may be used. 

INFLAMMATION OF THE PIA MATER. 
LEPTOMENINGITIS. 

By cerebral meningitis, inflammation of the pia ma- 
ter is commonly understood. Cerebral meningitis may 
be either simple or it may be dependent upon the de- 
posit of tubercles. The latter is the more frequent, 
and the disease is much more common with children 
than with adults. In adults, considering all cases, sim- 
ple meningitis is more common than among children ; 
indeed, it is so rare in childhood that some authors 
have denied its existence. 

^Etiology. — Non-tubercular meningitis may be pri- 
mary or secondary. When primary, it is often impossi- 
ble to discover the cause ; at other times there has been 
exposure to the sun, mental anxiety or overwork, great 
physical exertions, the influence of cold and dampness ; 
alcoholic excess has also been mentioned as a cause. 

Meningitis may be secondary to disease of the bones 
enveloping the brain, as the temporal bone in diseases 
of the ear. An obstinate or long-persisting otorrhcea 
should therefore never be neglected. Never neglect 
purulent otorrhcea under the impression that it is com- 
paratively harmless. 

Injuries to the cranial bones and fractures may give 
rise to caries and to meningitis ; so also may syphilitic 
disease of the bones, and some intra-cranial affections, 
as tumors and abscesses. 

Meningitis may be secondary to acute diseases, as 
pneumonia, pleurisy, cardiac lesions, eruptive fevers, 
erysipelas of the head, rheumatism, dysentery, perito- 
nitis, and diphtheria ; Bright's disease is occasionally 
complicated with meningitis. 



54 DISEASES OF THE BRAIN. 

Pathological Axatomy. — The lesion may occupy 
either the base of the brain or the convexity, or it may 
be limited to a circumscribed area only. The smaller 
vessels are distended with blood, the large veins are 
full. There is more or less serum exuded from the ves- 
sels into the meshes of the pia mater. Along the ves- 
sels are collections of pus, mixed with fibrinous exuda- 
tion. If this is in comparatively small amount, it is 
found only in the sulci ; otherwise it may be spread over 
the convexity. At the base of the brain it is collected 
also in the depressions, by preference around the pons ; 
under the posterior lobe, near the crura cerebri ; be- 
tween the crura ; and around the optic nerves. This 
exudation is not free fluid, but is contained in the 
meshes of the pia mater, which is swollen, or a fibri- 
nous exudation may contain pus and serum ; it may be 
large in amount, especially at the base, and the nerves 
may be surrounded by a thick, comparatively firm 
fibro-purulent sheath. 

In very chronic cases there may be found thickened 
patches in the pia mater, composed of fibrous tissue 
among whose fibers the microscope shows pus-cells. 

In cases of moderate duration the membranes, on 
being stripped off, may carry away portions of the gray 
substance. 

Sometimes the ventricles are distended with serum ; 
but this is less common than in tubercular meningitis. 
If they are distended, their lining membrane, the epen- 
dyma, is found thickened or covered with granulations, 
and it may be softened. 

Symptoms. — The commencement of the disease is 
usually acute. Occasionally, for a few hours or days, 
there are headache, vomiting, and dizziness ; but these 
prodromata are not common ; there is not, as a rule, 
the preceding ill-health which is so often seen in tu- 
bercular meningitis. 

The initial symptom is a severe headache ; occasion- 
ally a chill, soon followed by vomiting ; the temperature 



INFLAMMATION OF TEE PIA MATER. 55 

rises quickly, even to 104° ; the pulse is rapid ; there is 
delirium ; sometimes there are convulsions ; toward the 
latter part of the first stage motor disturbances appear, 
either paralysis or contractions. The second stage is 
characterized by coma and the destruction of all the 
vital powers. 

The duration of the disease is from a few hours to 
several days. When the disease is secondary to some 
other affection, the duration may be very short. When 
a large part of the convexity is affected, life is usually 
not prolonged beyond a few days ; when the disease 
is limited to the base, the patient may live several 
weeks. 

If the patient lives but a few days, the initial symp- 
toms will be quickly followed by the more serious, and 
the final stage will almost immediately succeed the 
earlier symptoms. If the disease is protracted, there is 
a more regular progression, and it may be possible even 
to divide the disease into stages. 

Headache is the most constant symptom, and is no- 
ticeable so long as consciousness continues, and even 
during delirium ; or in a child too young to speak, the 
knitted brows, the restless motion of the head, the 
hands carried to the head, the moaning and crying, 
clearly show that there is headache. The pain is more 
frequently general, but sometimes is confined to the 
frontal or occipital regions. 

The temperature is high at the beginning of the dis- 
ease. When there is meningitis of the convexity, the 
temperature remains high, and shows less variation 
than when the base alone is affected. 

The pulse may be at first rapid ; subsequently it be- 
comes less rapid, and fluctuates independently of the 
temperature ; toward the close of life it may become 
excessively rapid again, but, if there is compression 
of the brain by exudations, it may fall even as low 
as 50. 

Respiration is not especially affected in the earlier 



56 DISEASES OF THE BRAIK 

stages, excepting that it may be very rapid in children ; 
but toward the close of life it may be irregular, and the 
peculiar rhythm, which has been named Cheyne-Stokes 
respiration, may be observed. (See page 10.) 

Vomiting may be an early symptom ; at first the 
ingesta are vomited, later it is bilious. Sometimes the 
vomiting does not appear until a later period of the 
disease. There are very few cases in which vomiting 
does not occur. The appetite frequently does not suf- 
fer, and the patients take food readily, though they 
soon reject it again. The vomiting is often very obsti- 
nate. 

Constipation almost invariably is extreme, and it is 
sometimes nearly impossible to obtain a motion. 

Delirium is one of the earlier symptoms when the 
convexity is affected, beginning suddenly with delu- 
sions or hallucinations ; the patients may try to rise 
and wander about, or they may become furious at re- 
straint. In other cases the delirium shows itself at 
first only as the patient is falling asleep ; it is more 
quiet, muttering, or talkative. 

In meningitis of the base, delirium is less constant ; 
but, when the convolutions adjacent to the base are 
affected, it may be present. 

In the later stages the mental powers are destroyed, 
the patient passes into coma, from which there may 
possibly be a slight awakening before death ; but this 
is less common than in tubercular meningitis. 

Convulsions are almost always present in meningitis 
of the convexity. When the base alone is affected, 
there is generally at least local spasmodic action of 
some of the muscles supplied by the cranial nerves. 

Contractions also occur ; there is rigidity of the 
neck, the muscles of the face may be affected, or 
there may be strabismus. It is not common to have 
permanent contraction of the limbs ; when they are 
affected, there is usually partial flexion. Attacks of 
opisthotonos, with tonic contraction of the extensors 



INFLAMMATION OF THE PI A MATER 57 

of the limbs, may be present and last for a few 
minutes. 

The abdomen is less frequently retracted than in 
tubercular meningitis ; yet this is sometimes seen, espe- 
cially when the disease is chiefly at the base of the 
brain. 

That disturbance of the vaso-motor nerves which 
leads to the easy production of the tdche cerebrate 
is less common in simple meningitis than in tuber- 
cular. 

The patient gradually passes into a state of coma, 
the delirium alternates with stupor, the convulsions 
diminish in frequency, the contractions are now re- 
laxed, again reappear, until finally coma is fully estab- 
lished; then there is dilatation of the pupils, relaxa- 
tion of the sphincters, the pulse becomes slow and 
irregular, but the temperature rises, the insensibility is 
profound, and the patient dies without a struggle. 
Death may, however, occur at an earlier stage during 
the delirium and convulsions. 

The headache is explained by the affection of the 
membranes, by the exudation and fullness of the ves- 
sels. Leucocytes wander from the vessels into the cor- 
tical layers of the brain, the circulation is interfered 
with, there is irritation of the nerve-cells ; hence the 
delirium, the convulsions. If the cortex is affected, 
these are more marked and more general ; if the base 
only is affected, there is less probability of delirium, and 
the convulsions and contractions are more likely to 
affect the muscles supplied by the cranial nerves. From 
over-stimulation may follow exhaustion ; hence the 
convulsions intermit. When the disease has produced 
destruction of the nerve-cells, which is rare, or when 
effusion into the ventricles has produced compression 
of the brain, or the exhaustion has become extreme, 
the last stage sets in, and there is coma. This sketch 
of an explanation of the symptoms is rather brief, but, 
by keeping in mind the physiological relations of the 



58 DISEASES OF TEE BRAIN. 

parts affected, it will often be easy to explain the vary- 
ing symptoms. 

When meningitis occurs in the course of acute dis- 
eases or as the result of injuries, necrosis of bone, etc., 
the symptoms are less clearly defined. The previous 
primary disease obscures the beginning of the menin- 
geal affection. (For a complete discussion of the pos- 
sible variations, Ziemssen's "Cyclopaedia," vol. xii, may 
be consulted.) 

After acute meningitis certain symptoms remain ; 
there is a chronic thickening and change which is per- 
manent. 

Local changes in the membranes and cerebral cor- 
tex may give rise to spasms of a few muscles or a 
limb, which may spread to all the limbs, becoming gen- 
eral convulsions. Spasms confined to one set of mus- 
cles, or which always begin in the same muscles, are 
characteristic of cortical changes. The situation of the 
disease can be localized in the motor centers corre- 
sponding with the affected limb. 

When the motor center is destroyed, there will then 
be paralysis of the limb instead of spasm. 

Meningitis is present in the beginning of these 
cases, but soon the brain -substance is affected ; there 
is then really encephalitis. Many times syphilis is 
the cause of these local changes in the membranes 
and cortex. 

Diagnosis. — The diagnosis from tubercular menin- 
gitis will be considered under the latter disease. Cere- 
britis commences less suddenly, and the febrile symp- 
toms are less severe ; the symptoms are generally more 
circumscribed. 

The eruptive fevers may be complicated with men- 
ingitis, but it is only occasionally that this is so ; ty- 
phoid fever is more frequently thus complicated than 
the others. The diagnosis is rendered more difficult 
because head symptoms occur without meningitis. The 
delirium is more active when there is meningitis, the 



INFLAMMATION OF THE PIA MATER. 59 

headache is more severe, and there are more frequently 
convulsions. 

The course of the pulse and temperature is less regu- 
lar than is normal in the eruptive fevers. The charac- 
ter of the delirium, the sudden change in the tempera- 
ture and pulse, a sudden increase of headache, the 
character of the convulsions — these data will aid in 
diagnosis, but there will often be a doubt. 

Cerebral symptoms during the course of acute rheu- 
matism are not always due to meningitis ; frequently 
an autopsy shows no change of the membranes ; occa- 
sionally, however, there is inflammation. The diagno- 
sis is extremely difficult, and usually the patient dies 
without a decision being reached. Yet more difficult 
are those cases in which severe cerebral symptoms occur 
on the first outbreak of rheumatic fever before the joints 
are affected. These cases are rare ; sometimes the cere- 
bral symptoms subside, and the articular phenomena 
aj)pear to clear up the diagnosis. 

Once in a while pericarditis is accompanied with 
delirium and other cerebral phenomena ; there is not 
necessarily meningitis ; the primary disease is shown by 
physical examination, and is the more important in 
treatment. 

The coma after epilepsy and in the course of Bright's 
disease may be recognized by the aid of the early his- 
tory, the thermometer, and a careful examination of 
the urine, keeping in mind, however, that albumen may 
be present in the urine passed after an epileptic attack 
or in meningitis ; the presence of marked oedema, asci- 
tes, or other serous effusions would also aid in diagno- 
sis. If the previous history can not be learned, a diag- 
nosis may be impossible. It should be kept in mind 
that meningitis may arise during the course of Bright's 
disease, as purulent inflammation of other serous mem- 
branes may occur. 

The possibility of poisoning should be remem- 
bered. 



60 DISEASES OF THE BRAIN. 

The diagnosis from alcoholism will be considered 
under the latter affection. 

Peogxosis. — The prognosis is very unfavorable ; a 
recovery is rare, and is almost never complete. The pa- 
tient, if life is not lost, is liable to have headaches, to 
have partial loss of memory and diminished intellectual 
power. " When a natural sleep takes the place of coma 
and the patient awakes without fever, without paraly- 
sis, with a clear mind, though acting slowly," the prog- 
nosis is favorable. 

Treatment. — When the disease is uncomplicated, 
and the patient is seen at the beginning of the attack, 
the treatment can be vigorous, and there should be no 
delay. If the patient's strength justifies, general bleed- 
ing is proper. If the patient is feeble, leeches may be 
applied over the mastoid bones ; blood may be drawn 
by cups from the nape of the neck. Cold to the head, 
uninterruptedly, and smart purgation, are to be em- 
ployed. Some advise blistering the scalp ; but this is 
of doubtful value. 

In this disease, as in others, a high temperature 
may be met by cold baths, repeated as the tempera- 
ture again rises, or a lukewarm bath, and showering 
the head with cold water has been advised. Of course, 
the patient's strength should be taken into account and 
all precautions taken, as in other acute diseases. Among 
drugs to lower temperature are salicylic acid and qui- 
nine in large doses ; antipyrin, in doses of thirty or forty 
grains, repeated, if necessary, in an hour or two, may 
lower the temperature. Iodide of potassium in large 
doses, repeated at short intervals, is of great value. 
If there is a suspicion of syphilis, mercurial inunctions 
should be used ; this has been strongly urged by some, 
even when there is no reason to suspect syphilis. Er- 
got has been recommended ; but its value is doubtful. 

The headache and delirium are exhausting ; they 
should be met by chloral and bromide of potassium in 
large doses, from twenty to fifty grains of each (one and 



TUBERCULAR MENINGITIS. 61 

a half to three grammes), repeated after half an hour or 
an hour if necessary. These can be given by enemata 
if the stomach will not retain ingesta. Small doses of 
chloral, under fifteen grains (one gramme), are of no 
value, but, even when frequently repeated, often seem to 
increase the delirium. Subcutaneous injections of mor- 
phia may be of great value to check convulsions and 
stop the obstinate vomiting. 

The patient's strength should be sustained by a 
proper diet ; if there is much vomiting, by nutrient 
enemata. Milk two parts, and lime-water one part, in 
very small amounts, beginning with a teaspoonf ul every 
half hour, is sometimes most valuable in vomiting. 
Sometimes it is necessary to give the stomach entire 
rest. 

Trousseau speaks most discouragingly of all treat- 
ment, and emphatically disapproves of all active and 
depressing measures. He says that in the two cases 
of recovery which he had, Nature deserves the credit 
rather than his art. 



TUBERCULAR MENINGITIS. 

Pathological Anatomy.— This disease, as is well 
known, consists in a more or less extensive growth of 
miliary tubercles in the pia mater and the inflammation 
excited thereby. In a large majority of cases the ba- 
cilli of tuberculosis are carried by the blood to the spot 
where they develop ; then the tubercles form upon or 
within the vessels, and the normal epithelial cells un- 
dergo a change by which a large number of smaller, 
more round, cells are formed by subdivision, until a 
small nodule is formed, by the continued growth of 
which the vessel is closed, and then fatty degeneration 
of these cellular elements gives rise to the yellow, case- 
ous centers which are seen in the larger nodules. These 
growths are found, not merely upon the vessels of the 
membranes, but also on those which enter the cortex of 



62 DISEASES OF THE BRAIX. 

the brain. The irritation of these nodules, and their 
interference with the normal nutrition of the mem- 
branes, give rise to inflammation ; hence there are add- 
ed to the miliary tubercles the injection and exuda- 
tions, the fibro-purulent deposits of meningitis. 

When the tubercles are many and of moderate size, 
it is easy to recognize them ; but when small and few in 
number, a careful examination will be necessary. 

The inflammation excited by these deposits of tuber- 
cle is not confined exclusively to the vicinity of the mor- 
bid growths, though it is generally more marked there. 
Pus may be found at a distance, especially along the 
course of the vessels. 

The ventricles are frequently filled with serum, some- 
times so distended as to cause compression of the brain 
and flattening of the convolutions. 

The pathological changes are fully considered in 
treatises upon pathological anatomy and upon chil- 
dren's diseases. 

In the vast majority of cases there are tubercles or 
cheesy deposits in other organs, whence the bacillus is 
carried to the brain. 

When there seems to be an exception, the question 
arises whether the disease may not have existed undis- 
covered. 

tEtiology.— Tubercular meningitis is much more 
common in early life — between two and seven years. 
Among adults it is the more frequent between the ages 
of twenty and thirty or thirty-five. Seitz found that, in 
every thousand deaths among adults, tubercles were 
present in the pia in fifteen cases. Males are more fre- 
quently affected than females. 

As tubercular meningitis is generally secondary to 
tubercular or cheesy deposits elsewhere, all those influ- 
ences which favor the development of such changes in 
other organs will act as predisposing causes of this 
disease. 

Symptoms.— Many times there has been a gradual 



TUBERCULAR MENINGITIS. 63 

failure of health preceding the outbreak of the symp- 
toms strictly due to the meningeal affection. The pre- 
ceding disease has undermined the general health. As 
the tubercles alone probably have little influence in 
producing the symptoms, which appear only when in- 
flammation arises, it is not possible to determine how 
long the morbid growths have existed. Whether some 
of the earlier symptoms, as heaviness, languor, change 
of disposition, occasional headaches, are caused by the 
tubercular deposit, or by inflammation localized around 
these, is not absolutely certain, but probably by the 
latter. 

Sometimes, owing to the primary disease, it is diffi- 
cult to recognize the beginning of the meningeal affec- 
tion ; at other times the onset is as sudden as in simple 
meningitis. There may be a chill, but headache is 
more frequently the initial symptom. In children, con- 
vulsions may occur early. Vomiting occurs sooner or 
later in almost all cases, but may cease after a few 
days ; there is constipation. There may be general 
hyperesthesia of the skin, also an over-sensitiveness to 
noise and to light. The patient will perhaps bury his 
face in the pillow to shield his eyes from the faintest 
ray of light. 

The temperature is very irregular. Sometimes there 
is high fever at the beginning, but less regularly so than 
in simple meningitis. Not unfrequently the tempera- 
ture is normal for several days ; then its course is irregu- 
lar. A very high temperature is not often found until 
toward the close of life. The pulse also varies, but 
does not vary with the changes of temperature. 

Convulsions may occur in the later stages of the dis- 
ease, and partial convulsions — as of the muscles of the 
face, of the eyes, or of mastication — are seen in many 
cases, producing contortions of the face, strabismus, 
etc. The head may be drawn back, or at least the neck 
be stiff ; the abdomen may be retracted. The pupils 
may react imperfectly or be unequal. Paralysis of one 



64 DISEASES OF TEE BRATK 

or more limbs, as well as of certain muscles supplied by 
cranial nerves, occur after a few days. The tache cere- 
brale can very generally be produced. 

The mental symptoms are sometimes delayed until 
a late stage, sometimes appear early ; irritability, mood- 
ishness, fretf ulness, and lack of mental vigor, may be 
among the earlier phenomena. Delirium is common, es- 
pecially on falling asleep ; it is not generally very vio- 
lent. Toward the close of the disease all mental func- 
tion is abolished, there is complete coma; then the 
more active symptoms — as spasms, contractions, cries, 
restlessness — cease. The temperature generally rises 
quickly, once in a while becomes lower. The pulse 
may be very slow. Respiration becomes irregular, the 
Cheyne-Stokes respiration may appear, and soon the 
patient dies. A short time before death intelligence 
may return ; there seems to be a very great improve- 
ment, which may well deceive the friends, but the phy- 
sician should be on his guard. 

Optic neuritis is quite common in tubercular menin- 
gitis, unless the disease is confined to the convexity. 
The neuritis is not often intense ; is sometimes so slight 
as to not be easily recognized ; it is rarely accompanied 
Avith haemorrhages. Both eyes are affected. 

It has been the custom to divide the progress of the 
disease into three stages : 1. Irritation ; 2. Pressure ; 
3. Paralysis or coma. 

Occasionally these stages are well defined, but more 
frequently they run into one another, and the symptoms 
occur with so little regard to orderly succession, that it 
is not possible to define the various stages. Rather 
than to describe the disease thus, I have preferred to 
give a general description, which, it seems to me, more 
nearly corresponds with what is seen in common prac- 
tice. 

The following explanation of the symptoms, con- 
densed from Huguenin, will assist to a better under- 
standing of the disease : The earlier prodromal symp- 



TUBERCULAR MENINGITIS. 65 

toms, if there are any, may depend upon disturbance 
of the nutrition of the brain, caused by the tubercles, 
possibly by irregular and variable irritation of the 
nerve-cells. Inflammation of the pia mater is excited 
by the tubercles ; the cortex is affected secondarily ; 
occasionally slight haemorrhages occur. The mental 
symptoms are those of excitement during the rise of 
the inflammation, the character of the mental disturb- 
ance varying with the locality of the inflammation, as 
different nerve-centers are affected. The hydrocephalic 
effusion will explain the symptoms of compression 
which are seen toward the close of the disease. The 
convulsions may be referred to irritation of nerve- 
centers in the cortex or to an irritation of the medulla 
oblongata, the latter especially if the convulsions are 
general. Rigidity of the muscles of the neck, and the 
weakness and peculiarities of gait, are not easily ex- 
plained, but may be due, not simply to the cerebral 
lesion, but rather to spinal complications. When pa- 
ralyses of individual limbs or of one side occur early, 
there is usually a local cause, easily recognized at the 
autopsy (as haemorrhage or local softening). When 
these occur late, the cause may escape detection. Local 
paralysis of individual cranial nerves may be explained 
by the effusion around the roots of these nerves, the 
neuritis or other degenerative changes set up in them. 

When the cortex is chiefly or exclusively affected, 
mental symptoms will predominate, with local spasms 
and paralyses ; when the base is chiefly affected, men- 
tal symptoms may be almost entirely absent ; general 
weakness, general spasms, paralyses of cranial nerves, 
and at length hydrocephalus, will be the principal symp- 
toms. 

Diagnosis. — The first question is naturally whether 
there is meningitis ; the second, whether, if present, it 
is simple or tubercular. The following enumeration of 
the more important symptoms is given by Seitz : "Head- 
ache ; vomiting ; constipation ; absence of roseola ; stu- 



6Q DISEASES OF THE BRAIX. 

pefaction ; confusion ; delirium ; obstinacy ; carpholo- 
gia ; stiffness of the neck, back, or muscles generally ; 
general hyperesthesia ; retracted abdomen ; paralysis 
of the pupils, eyelids, eyes, of the face, of the limbs ; 
trembling ; twitching ; convulsions ; old phthisical affec- 
tion of the lungs, and other chronic inflammatory, sup- 
purating, and caseous processes ; duration of the disease 
from two to four weeks with fatal termination." 

The diagnosis from simple meningitis is not by any 
means always easy. The diagnosis will be facilitated 
by bearing in mind, that in children tubercular menin- 
gitis is much the more common, while in adults simple 
meningitis is the more prevalent. 

The condition of health preceding the attack is an 
important element in diagnosis. The tubercular form, 
as a rule, begins less acutely, the duration is longer, and 
the course more irregular. 

The temperature is less steady, may be moderately 
elevated only for a few days, may be below normal, is 
rarely very high, excepting toward the close of life. 
In simple meningitis the temperature is higher at the 
commencement, and is more regular. The pulse is fre- 
quently slow in tubercular meningitis, and does not 
necessarily follow the variations of the temperature. 

Tubercular meningitis is the more often accompa- 
nied with paralyses of the cranial nerves, and even of 
the extremities. 

Convulsions, retracted abdomen, taches cerebrales, 
contractions, vomiting, constipation, and the variations 
in respiration, give but little aid in forming a diagnosis 
between the two forms of meningitis. 

It is very important to distinguish the pseudo-hydro- 
cephalic state found in infants, especially during diar- 
rhoea, dysentery, and other exhausting diseases. This 
will be considered under Cerebral Anaemia. 

It will sometimes be necessary to guard against be- 
ing deceived by the possibility of reflex irritations, as 
teething, ingestion of improper food, and worms, which 



TUBERCULAR MENINGITIS. 67 

may give rise to convulsions and other doubtful symp- 
toms. 

Wilks makes the following statement : " If you meet 
with an obscure case of recent disease, to which you can 
only apply the term cerebral, without being able to de- 
clare the existence of any special lesion, it will gener- 
ally turn out to be a case of meningitis." This is rather 
too sweeping, but contains considerable truth. 

Prognosis. — Trousseau mentions two cases of par- 
tial recovery in children, one with paralysis. The child 
died five months later from dysentery, and the traces 
of the old disease were found at the autopsy. In adults 
it is very doubtful whether recovery is possible, and 
even in children the recoveries are so few that practically 
there is no reasonable hope of a favorable termination. 

Treatment. — It is almost hopeless to try to do any- 
thing, but we can refrain from being too meddlesome. 
The active treatment, which might be of advantage in 
simple meningitis, would not be called for in the tuber- 
cular. The cases reported as recovering were treated, 
some by ergot in large doses, and some by iodide of po- 
tassium in large doses frequently repeated. 

As in many cases a diagnosis is doubtful, and as 
simple meningitis is amenable to treatment, it will often 
be most wise, excepting depleting measures, to treat a 
case of suspected tubercular meningitis as if it were 
simple meningitis. 



CHAPTER IV. 

CHANGE IN BLOOD-SUPPLY. 

Jokes, C. H., Studies on Functional Nervous Disorders. Lon- 
don, 1870, p. 64, 86. — Fothergill, J. M., Cerebral Anaemia. West 
Riding Hospital Reports, vol. iv, 1874, p. 94.— Motta, E. A., 
Ueber Hirnanamie im Algemeinen und insbesondere iiber Blutleere 
des Gebirns und iiber dessen consecutive Erweichung. Deutsche 
Klinik, 43, 1874.— Mitchell, Weir, Fat and Blood. Philadelphia, 
1877.— Hewitt, Graily, Chronic Starvation. London Lancet, 
Jan. 11, 1879, p. 38.— Ball, Benj., On Certain Cases of Function- 
al Ischemia of the Brain. Brit. Med. Jour., Oct. 30, 1880, p. 693. 
— Jaccoud, S., Traite de pathologie interne, 1870, t. i, p. 106.— 
Moxon, Walter, Influence of the circulation upon the nervous 
system. Brit. Med. Jour., 1881, I. 

CEREBRAL ANAEMIA. 

Among the conditions of the brain most difficult for 
diagnosis are those in which there is irregular blood- 
supply. There are several reasons for this : 1. An over- 
worked brain is an exhausted brain ; not only are the 
proper cerebral nervous elements exhausted, producing 
irregular action, but the vaso-motor nervous supply 
also may become irregular from exhaustion of the vaso- 
motor nerves. 2. Another cause for mistake is that a 
badly nourished brain is irritable. Hence many of the 
symptoms of exhaustion and of malnutrition resemble 
those found in congestion or stimulation from excess 
of blood. 3. Poor blood, that which is not suitable for 
nourishment, may be sent in large amount to the brain, 
and there will still be practically anaemia ; the nervous 
structures may have lost their power of absorbing the 



CEREBRAL ANAEMIA. 69 

nutrient materials from the blood, and the same results 
follow. 

Under anaemia it is intended to comprise all those 
conditions wherein there is insufficient nutrition of the 
brain, owing to defect in quantity or quality of the 
blood. 

^Etiology. — When there is general anaemia or chlo- 
rosis, the brain usually suffers more or less from an in- 
sufficient supply of healthy blood. Those conditions, 
then, are causes of cerebral anaemia which give rise to 
general anaemia, as haemorrhages, deficient supply of 
food, bad hygienic surroundings, exhausting discharges, 
whatever causes a poor appetite or poor digestion, etc. 

A hindrance to the flow of blood to the brain, as 
pressure on the arteries, obstruction of their caliber by 
atheroma, arteritis, spasm, embolism, thrombosis, may 
give rise to a deficiency of blood-supply in the brain as 
a whole, or their influence may be local, and limited to 
a small area. The same result follows a weakening of 
the heart's action, so that the blood is not sent with 
sufficient force to fill the cerebral vessels. 

Deficient oxidation, absorption of poisons, overheat- 
ing by sun or artificial heat, hyperpyrexia in fevers, 
etc., cause a defect in the quality of the blood, render- 
ing it unfit for the healthy nutrition of the brain. 

Though not immediately acting upon the supply of 
blood nor its quality, it is necessary to consider the 
conditions under which the patient has lived. Not 
only do anxiety and worry, but overwork, mentally or 
bodily, and loss of sleep, by exhausting the nervous 
system, have a tendency to give rise to an irritability 
of the brain, which causes it to show the effects of defi- 
cient blood-supply more quickly. 

There are very few cases where diminished blood- 
supply alone is the cause of the symptoms. It is only 
in the acute cases following sudden haemorrhage that 
this is true, and even in these there is subsequently de- 
ficient quality of blood. Generally changes in quality 



70 DISEASES OF THE BRAIK 

concur in causing the symptoms. Some of the diseases 
in which the symptoms of cerebral anaemia may be 
found, caused by changes in the nutrition of the blood, 
are dysentery, diarrhoea, gastric catarrh, phthisis, sup- 
purative diseases, syphilis, typhoid and other fevers, 
and malarial poisoning. 

Pathological Anatomy. — There is simply paleness 
of both white and gray substance, comparative empti- 
ness of the blood-vessels, and, excepting there be com- 
pression from some cause, moisture of the cut surface. 
The lymph-spaces are filled with serum or lymph to com- 
pensate for the diminished fullness of the blood-vessels. 
In chronic cases there is undoubtedly change of nutri- 
tion ; but our means of examination do not enable us to 
recognize such change. 

In local anaemia from obstruction of blood-vessels, 
changes occur which will be more properly considered 
elsewhere. 

Symptoms.— The symptoms vary according as the 
anaemia is acute or has come on gradually. If the pa- 
tient has been exhausted by previous disease, the symp- 
toms will be less violent than if he has been in vigorous 
health. Whether the brain has been overworked and 
excited must also be taken into consideration. 

When a rapid haemorrhage causes cerebral anaemia, 
the attack is acute, there is a loss of mental power, ver- 
tigo, dimness of sight and of hearing, tinnitus, sensa- 
tion becomes blunted, the pupils are contracted, then 
dilated, the skin is cool, consciousness is lost, and con- 
vulsions occur. Respiration is accelerated, then slow ; 
pulse small, frequent, and of diminished tension. This 
combination of symptoms may be seen not only in se- 
vere haemorrhages, as in surgical and obstetrical prac- 
tice, but less completely developed where a patient 
greatly exhausted rises from the bed too suddenly ; 
also in ordinary fainting from whatever cause. 

The description of more chronic forms of cerebral 
anaemia is rendered difficult by the fact that very few 



CEREBRAL ANAEMIA. 71 

cases are uncomplicated. Nervous exhaustion, from 
anxiety, worry, fatigue, or overwork of brain, serves to 
intensify or change the symptoms ; also the symptoms 
of anaemia and hyperemia of the brain are very similar 
— so similar that it is oftentimes impossible to decide 
which condition is present without regard to preceding 
circumstances. Again, an irritable brain, anaemic as a 
whole, may be locally congested, or may receive tem- 
porarily an increased supply of blood, though a supply 
below that appropriate for health, and, owing to its ab- 
normal irritability, be excited as if hyperaemic. 

In chronic anaemia, thought is an effort, sustained 
mental exertion is impossible, memory is uncertain, the 
patient is drowsy ; occasionally after rest there may be 
flashes of brilliancy, but they are brief. If effort is 
absolutely necessary, the patient may have learned that 
a very small amount of wine or spirit is a temporary aid. 
Headache is one of the most annoying symptoms, and 
is very persistent, and may incapacitate for the ordi- 
nary duties of life. After lying down long and being 
quiet, the headache may be relieved, but recurs on at- 
tempting to go about. Perhaps, in part owing to the 
headache, in part owing to the malnutrition of the 
nerve-centers, there is likely to be a change of disposi- 
tion ; irritability of temper, fretfulness, and peevish- 
ness are seen. Sometimes there is dizziness ; more fre- 
quently there are noises in the head, tinnitus aurium, 
also various disturbances of vision, muscae volitantes, 
dimness, even amaurosis, though the latter is rare. 
Respiration may not be much changed, but there may 
be a feeling of discomfort, as if not air enough were 
inspired, and so there is sighing. The pulse usually 
varies only slightly from the normal, unless there is 
present some disease to account for an increased rapid- 
ity, as phthisis. The same is true of the temperature ; 
it is usually about normal or a little below, but may be 
elevated if any febrile affection exists. General weak- 
ness is almost always seen, but rarely complete paraly- 



72 DISEASES OF THE BRAIK 

sis. Convulsions are not seen in cases of chronic anae- 
mia. 

When the anaemia is very great, there may occur 
delirium ; if the anaemia has come on with moderate 
rapidity in a rather vigorous person, without previous 
disease, the delirium is usually active, the patient may 
even be maniacal, and may have hallucinations, hear- 
ing voices, and holding conversations with imaginary 
persons ; he may not recognize his friends, or may de- 
sire to escape. This feature of cerebral anaemia has so 
much the appearance of excitement from hyperaBmia 
that many refer it to such a condition, su}:>posing that 
there is local congestion ; but the active delirium is 
seen only when the affection has been developed rather 
rapidly, and is probably owing to the state of irritable 
weakness, to which reference has already been made. 
When the anaemia occurs during the course of an ex- 
hausting disease, either as a result of the disease or of 
insufficient feeding, the delirium is more likely to have 
a quiet character. Finally, the mental powers may be 
entirely lost. 

Diagnosis.— In forming a diagnosis of this affection 
it is necessary to take into consideration the previous 
circumstances of the patient. The diagnosis from hy- 
peremia may be very difficult, and, as the treatment 
would be quite different, it is important to be as nearly 
correct as possible. If there is a history of long-con- 
tinued, privation, with worry and anxiety, or of hard 
work, physical or mental, and loss of appetite, or ex- 
hausting discharges, it is probable that the condition 
is anaemic, although there may be much excitement. 
It is sometimes more difficult to decide, where there is 
active delirium, whether it is insanity or anaemia. Here 
also the previous history will be of assistance ; but, as 
anaemia may lead to change of structure in the nerve- 
cells, it may pass over into insanity, and without mania 
it may pass into melancholia. In insanity induced by 
cerebral anaemia there is not a long-continued period of 



CEREBRAL ANEMIA. 73 

excitement ; the condition is rather one of depression, 
with occasional attacks of irritability. 

To recognize that delirium in febrile diseases is ow- 
ing to cerebral anaemia is all-important. Especially in 
children with gastro-intestinal affections the symptoms 
resemble those of serious organic brain disease ; the 
previous history must not be overlooked ; it would be 
disastrous to treat a child with anaemia for meningitis. 
During typhoid fever in adults there may be a similar 
mistake. It would seem that care in watching the 
patient — not only the fever, but also the feeding of the 
patient — might prevent such an error. Excessively high 
temperatures may give rise to symptoms similar to those 
of anaemia ; a careful use of the thermometer will guard 
against this mistake. 

Prognosis. — If there is no serious complication, as 
cardiac or Bright's disease, the prognosis is favorable, 
provided sources of exhaustion can be removed. The 
prognosis in the case of other diseases may be favor- 
able for the anaemia, though unfavorable for the pri- 
mary disease. 

Treatment. — If the case is one of acute anaemia, 
or of extreme weakness after protracted disease or ex- 
hausting discharges, it will be very important to keep 
the head low ; perhaps the foot of the bed should be 
raised ; the body should be kept warm, by artificial 
means if necessary ; stimulants may be necessary ; food 
in a form easily digested, in small amounts, frequently 
repeated. 

The chronic form needs methodical rest and feed- 
ing. As many of the symptoms are due to exhaustion 
of the nervous system, the effort should be made to 
withdraw the patient from all such influences as tend 
to exhaust him. In many cases the course of treat- 
ment recommended by Weir Mitchell in "Fat and 
Blood" will give excellent results. In every case the 
best tonic is food. The food must be easily assimilated, 
not in too great quantities, and should be taken at short 



74 DISEASES OF THE BE A IX. 

intervals. Milk is one of the best to begin with ; not 
only is it easily digested and contains all the constitu- 
ents of the body, but is largely composed of water. 
Fothergill's remarks about water in anaemia are deserv- 
ing of attention.* Among drugs, arsenic, iron, and 
quinine are valuable. 

Where there is restlessness, sleeplessness, delirium, 
it may be necessary to give chloral and bromide of po- 
tassium, or paraldehyde. Small doses of these are 
worse than useless ; even if frequently repeated, they 
are not efficacious ; less than twenty grains of each 
is not sure of giving rest ; in many cases it may be 
necessary to give thirty or even forty grains at one 
dose. Yet chloral should be given with caution, and 
not administered every time a patient does not sleep ; 
it is often given injudiciously. Spirit will sometimes 
aid sleep. Opium is a valuable agent, and may often 
be given to advantage in small doses — a tenth or twelfth 
of a grain — the object being rather to obtain its stimu- 
lating effect. Sleep may sometimes be produced by a 
grain or two or quinine at bedtime, or by a dose of 
phosphoric acid, or by a light lunch just before retir- 
ing. A cup of beef-tea during the night may overcome 
the habit of lying awake. 

CEREBRAL HYPEREMIA. 

"When the arteries are distended, or there is an in- 
creased flow of blood through them, there is active hy- 
peremia ; when the veins are over-distended, it is pas- 
sive. The latter condition may, in reality, be one of 
anemia, so far as concerns the state of the circulation 
in the brain. 

Some authors deny the existence of cerebral conges- 
tion. 

Causes. — Probably a predisposition to cerebral hy- 
peremia is constitutional with some persons, just as 

* " Handbook of Treatment," pp. 51, 52. 



CEREBRAL HYPEREMIA. 75 

some blush more easily than others ; the predisposition 
may be acquired. Whatever has a tendency to cause a 
fullness of the cerebral arteries, and keep the blood 
flowing rapidly through the brain, may give rise finally 
to a predisposition to cerebral hyperemia. Excessive 
and often-repeated emotional disturbances, excessive and 
protracted brain- work, are among these agents. But 
it must be kept in mind that these also produce exhaus- 
tion, and so irritability, which may lead the brain to 
respond unhealthily to the normal amount of blood, or 
to be excessively excited by less than the normal 
amount. 

Among other influences may be mentioned a low 
temperature ; thus, most cases are said to occur in win- 
ter. A very high temperature is also said to cause con- 
gestion, and especially if the sun shines directly upon 
the head ; but the symptoms following such exposure 
are rather due to elevation of temperature and change 
in the quality of the blood. 

Increased activity of the heart is also said to be a 
cause of cerebral congestion ; hence violent exertions 
may give rise to it. 

Certain drugs may cause cerebral hyperemia, as 
nitrite of amyl. Opium and belladonna have been 
thought to do so ; but this is not certain. Alcohol may 
act as a cause, but only acutely : chronic alcoholism 
acts rather by producing changes in the quality of the 
blood, and so changes in the nerve-structures. 

Malarial poison may excite congestion of the brain ; 
indeed, probably every attack of chills and fever is at- 
tended with cerebral hyperemia, and this may be one 
cause of danger in severe malarial diseases. 

Passive congestion may be caused by any interfer- 
ence with the return of the blood from the brain. 

Pathology. — In acute cases very little change may 
be expected ; much or most of the blood drains off post- 
mortem. Yet even then, and with rather more fre- 
quency in cases of longer standing, the smaller vessels 



76 DISEASES OF THE BRAIK 

in the cerebral substance show with unusual distinct- 
ness upon section. The surface of the section is thickly- 
sprinkled with bloody points, the gray substance is 
darker, and the white substance may have a decided 
pinkish color, from the fullness of the minutest vessels. 

In chronic cases the constant dilatation of the ves- 
sels may lead to changes around them ; the perivascu- 
lar sheaths may contain granules of blood pigment. 
There are seen, also, cavities in the brain containing the 
transverse section of a vessel. These are thought by 
some to be caused by dilated perivascular sheaths, by 
others to be dependent upon dilatation of the vessels. 
The latter may act as one agent in their production, 
another may be shrinking of the cerebral substance, a 
slight atrophy which causes a dilatation of the peri- 
vascular sheaths. 

Constant and repeated hyperemia must interfere 
with the nutrition of the nervous structures ; the high 
blood-pressure is unfavorable for the interchange of 
elements. The changes thus resulting occur slowly, but 
finally may be very serious and may lead to insanity. 
These changes will also explain why it often requires 
so long a time for recovery from symptoms which seem 
insignificant. In this connection it must be remem- 
bered that not only do the proper structures of the 
brain suffer, but also the walls of the blood-vessels and 
their vaso- motor nerves undergo changes — at least 
functional changes, and probably slight organic changes. 

Symptoms. — Many of the symptoms of cerebral hy- 
peremia are the same as are found in cerebral anamiia, 
and many which are usually ascribed to hyperaemia are 
quite as dependent upon exhaustion from overwork, 
anxiety, etc. It is impossible to entirely separate the 
two classes of symptoms in giving an account of the 
affection. 

If not severe, there may be a sense of heaviness, or 
pain in the head, with tinnitus (though this is more 
common in anaemia), dizziness, sleeplessness, more or 



CEREBRAL HYPEREMIA. 7? 

less agitation, perhaps at times a tingling sensation in 
the fingers or feet, as if they were "asleep." These 
symptoms at first recur only occasionally, but may be- 
come more permanent. 

There may be more serious symptoms : the tempera- 
ment may be changed and the patient be fretful and 
irritable, the mental power diminished, and there may 
be absolute inability to apply the mind in certain direc- 
tions. When an intense application of the mind to one 
class of questions has brought on the affection, there is 
inability to apply the mind in that direction. A teacher 
can not teach ; the effort to do so may cause such con- 
fusion that he will have no command over his speech ; 
or a lawyer may be unable to try a case before a jury, 
the attempt to do so being preceded by sleepless nights, 
and accompanied by such distress, or even semi-delirium, 
as to make it impossible. It would seem as though in 
these cases there is a local irritability of the nerve- cen- 
ters relating to such pursuits, which, when an attempt 
is made to use these centers, gives rise to an increased 
flow of blood, not only to them, but to other parts of the 
brain also. It is interesting to note that the use of other 
centers has not this effect : thus, the lawyer who can not 
try a case in court may be able to attend to other busi- 
ness (though it is not by any means safe to allow it) ; 
the merchant may not be able to keep the run of his 
goods, but he can attend to his garden and care for his 
country residence without distress. 

Memory is affected: there is confusion, dullness, 
wrong words are used in talking ; there may be deliri- 
um, or the excitement may run into mania. At times 
there may be weakness of the limbs, twitching of mus- 
cles, especially of the face ; paralyses almost never oc- 
cur ; convulsions belong rather to anaemia or epilepsy ; 
and also disturbances of sight and hearing are more fre- 
quent in anaemia ; vomiting is rare. Respiration is little 
affected ; the pulse is usually full and resistant, perhaps 
rapid, possibly moderate. The face is usually flushed 



7S DISEASES OF THE BRAIN. 

or ruddy, is rarely pale, and the conjunctivae may be 
injected. 

Many authors describe a form of this affection at- 
tended with convulsions, which, however, Trousseau 
refers to epilepsy, and this explanation is now gener- 
ally accepted. 

There is a condition which I have met a few times 
which seems to be dependent on congestion rather than 
anaemia. I have only seen it in women run down ner- 
vously ; so nervous exhaustion is one element in causing 
it. The patient, after some emotion or shock, only 
slightly more severe than usual, or after some exertion, 
as ascending stairs, feels weak, is unable to stand or sit, 
has distress in the head, then loses all power of motion, 
and speech ; lies as if in a faint, but the face is flushed ; 
the heart beats vigorously, perhaps not more so than 
normal ; respiration is little if at all affected. If the 
attack is not severe, the patient may lie utterly help- 
less, unable even to move an eyelid, yet know all that 
is said and done. In severer cases, consciousness is lost. 
I have known such an attack to last two or three hours. 
There is no spasmodic action. Recovery is gradual, 
then respiration may be sighing ; subsequently there is 
great distress in the head and confusion of thought for 
several hours. 

These attacks may occur during the night, either in 
consequence of a dream or from the previous day's ex- 
haustion and the recumbent position. One gentleman 
told me that, after learning that his wife had these, the 
peculiar respiration, in her case noisy, aroused him. 
These attacks differ from epilepsy in that a definite 
cause can be so frequently traced that it is reasonable 
to think such a cause always exists ; they recur as ir- 
regularly as the causes which give rise to them. 

Diagnosis. — It is not always easy to distinguish 
congestion from ansemia or from simple nervous ex- 
haustion. Sometimes it is necessary to suspend judg- 
ment for a while to watch the course of the symptoms. 



CEREBRAL HYPEREMIA. 79 

A superficial examination of the patient will be as likely 
to lead to an error in diagnosis as to give correct re- 
sults. 

Some physicians recognize hyperemia in almost 
every obscure morbid functional state of the brain ; 
others disbelieve in it entirely. 

The previous history of the patient will assist mate- 
rially in diagnosis. Has the patient been well fed, or 
poorly \ been happily situated, or miserably % had pros- 
perity or poverty % have there been exhausting drains 
upon the system, frequent small haemorrhages, or se- 
verer haemorrhages % Is the patient full-blooded or gen- 
erally anaemic ? Is the face ruddy, flushed, or pale ? 
Did the attack come on as the result of excitement, or 
during the strain of some intense mental effort, or dur- 
ing a violent physical exertion? All these inquiries 
will assist in forming a correct diagnosis when the 
symptoms are uncertain. 

A diagnosis depending upon the symptoms may be 
made in many cases with some degree of probability. 
In anaemia the symptoms are those of excitement only 
in rare cases, and then the excitement is not of long 
duration ; as a rule, in the more chronic cases there is 
depression. In hypersemia, excitement and exaltation 
predominate, and there is apparent depression only 
when the brain is overpowered by the severity of the 
attack, or the congestion is passive. The headache is 
more acute in anaemia ; more of a feeling of painful full- 
ness in hypersemia. The pulse is fuller and more 
bounding in hypersemia. These peculiarities, with at- 
tention to the whole group of symptoms as described 
above under both these affections, will in most cases 
lead to a correct diagnosis. It would be easy to pick 
out typical cases of both these conditions from actual 
practice and describe them, but such cases are not 
easily mistaken, and, unfortunately, form only a small 
proportion of the cases we see. As in many other 
diseases, a careful examination and consideration of 



80 DISEASES OF THE BRAIX. 

all the circumstances are necessary to a correct diag- 
nosis. 

Other affections which must be separated from cere- 
bral congestion are cerebral haemorrhage, cerebral em- 
bolism, and thrombosis. These will be better consid- 
ered under those affections. Vertigo from disease of 
the ear and from derangement of the digestive organs 
also needs to be distinguished. 

The most important affection, next to ansemia, to 
correctly recognize is epilepsy. Some forms of epi- 
lepsy are so obscure, especially in the commencement 
of that affection, that it is no uncommon circumstance 
to have it overlooked, and the patient, his friends, and 
perhaps the physician, consider the attack is a mere 
passing rush of blood to the head. This will be more 
intelligently considered under epilepsy. 

A reasonable care in the examination of the urine 
will suffice to distinguish Bright's disease, which may 
give rise to symptoms closely resembling those caused 
by disturbance of the cerebral circulation. The urine 
should be examined more than once if the diagnosis is 
doubtful. 

Prognosis. — The danger from an attack of cerebral 
congestion depends upon the severity of the attack and 
its suddenness. The brain may be completely over- 
powered by the sudden influx of blood, consciousness 
may be lost, and, if the medulla is also affected, life 
may be extinguished at once or very soon. Walter 
Moxon, however, finds no satisfactory post-mortem evi- 
dence that acute congestion is ever a cause of death. 

But generally the patients do not die at once, and 
in chronic cases there seems to be no immediate danger 
to life. Recovery, however, is tedious. Almost al- 
ways there have been various circumstances in the pa- 
tient's history acting as predisposing causes, and this 
is one reason for the slow recovery. Where there is no 
complication, a recovery may be expected in time, pro- 
vided the patient will submit to proper treatment. 



CEREBRAL HYPEREMIA. 81 

Among other complications, the most unfavorable is 
organic change in the nervous elements of the brain. 
This may give rise to insanity. 

Teeatment. — Congestion of the brain may be ac- 
companied with so severe symptoms, with snch imme- 
diate danger to life, with unnatural fullness of the 
arteries, with such strong action of the heart, that gen- 
eral bleeding is indicated. These cases are, however, 
rare, and such bleeding would not be advisable in any 
except a robust and plethoric patient. Local bleeding 
by cups or leeches would be beneficial in a larger num- 
ber of cases. In the severer forms, when it is not de- 
sirable to withdraw blood, means may be taken to in- 
crease the flow of blood to distant parts of the body, as 
by hot foot-baths or mustard foot-baths ; or to diminish 
the amount of blood by acting on the bowels, saline 
cathartics, croton - oil, etc. ; or by promoting copious 
sweating by hot-air baths, steam baths, hot -water 
baths, keeping ice on the head. Jaborandi acts espe- 
cially on the skin ; but, as it frequently gives rise to vio- 
lent vomiting, it would be hardly safe, lest the straining 
in vomiting should increase the congestion. 

Cold applications to the head — ice, a rubber tube 
coiled up, with cold water running through it, evapo- 
rating lotions — may give relief ; but to be of much bene- 
fit, the application must be continuous. 

When there is violent delirium, mania, as one of 
the most marked symptoms, it will be frequently found 
that there have been circumstances tending to render 
the brain excitable. The measures already mentioned 
may be employed : sometimes a wet cup to the back of 
the neck taking a few ounces of blood aids in giving 
relief ; sometimes a dry cup gives equal relief. Bro- 
mide of potassium and chloral, in doses sufficient to 
produce sleep, are especially indicated ; from thirty to 
sixty grains of each. Small doses of chloral repeated 
hourly have no effect, but rather aggravate the symp- 
toms, and the combination of the two drugs is more 



82 DISEASES 01 THE BRAIN. 

efficacious than either alone. Hyoscyamus will often 
procure sleep and quiet if given in large doses. In cases 
of mania from cerebral hyperemia, opium should not 
be given, but during delirium from anaemia it may be 
beneficial. 

Where the hyperemia is chronic and has been pro- 
duced by excessive mental application, or by constant 
emotional excitement, the first indication is to remove 
the cause. The patient should drop his studies, his 
business, whatever has intensely occupied him, and 
withdraw from all associations which give rise to emo- 
tional disturbance. A quiet, regular, systematic life, 
with easily digested, mild food, is the most favorable. 
Bromide of potassium, without chloral, fifteen or twenty 
grains three times a day. Bromide of sodium, lithium, 
calcium, or ammonium, have been used instead, and 
are more agreeable to some patients. Ergot, either as 
fluid extract, half a drachm to a drachm, or ergotin, 
three to five grains, three times a day. Ice to the back 
of the neck will sometimes relieve the discomfort in 
the head better than when apyxLied to the head directly. 

Most cases of chronic cerebral hyperemia are also 
complicated with nervous exhaustion, and it may be 
desirable to give tonics to counteract the exhaustion. 
The vaso-motor nervous system is at fault, and requires 
not only a temporary stimulant to cause the arteries to 
contract, but it needs also to be permanently strength- 
ened. A systematic course of hydrotherapy may be of 
value in this direction ; also the ordinary tonics. 

The chief object of these remedies is to restore the 
normal action of the arteries and the vaso-motor nerves. 
To do this, iron, strychnia, arsenic, quinine, zinc, nu- 
tritious but unstimulating food, are the most valuable 
agents. Spirituous liquors are to be avoided ; tea and 
coffee taken only in moderation, if at all ; tobacco 
should be forbidden. It is scarcely necessary to men- 
tion that the digestive and other functions should be 
kept in a normal condition. 



CEREBRAL HYPEREMIA. 83 

Those who have had attacks, or who seem liable to 
attacks of cerebral congestion, should avoid public 
gatherings where the air is likely to become impure 
and heated, and where there is more or less excitement, 
as theatres, concerts, balls, etc. They should be quiet 
in all their movements, avoiding exertions which would 
cause an increase of blood - pressure in the brain, as 
running, lifting weights, straining at stool, and venereal 
indulgence. They should sleep in cool, well-ventilated 
rooms ; better on a hair mattress, with head elevated. 
They should take exercise in the open air, but avoid 
being chilled in cold weather. All intellectual efforts 
which produce the least discomfort in the head should 
be avoided. As one can not stay at home surrounded 
by familiar objects without the mind running more or 
less in its old ruts, and being recalled by old associa- 
tions into old trains of thought, it is especially impor- 
tant to break up all such associations in cases of chronic 
hyperemia, and, where the patient's health permits, 
traveling or a sojourn away from home is very desira- 
ble. Often it is the method whereby quickest relief 
can be obtained. 



CHAPTEE V. 

HEMOREHAGE. 

Charcot et Bouchard, Nouvelles recherches sur la patho- 
genie de l'hemorrhagie cerebrale. Arch, de physiol., 1868. — Du- 
rand, C, Des anevrysmes du cerveau consideres principalement 
dans leurs rapports avec rhemorrhage cerebrale. Paris, 1868. — 
Bourneville, Etudes cliniques et thermometriques sur les mala- 
dies du systeme nerveux. Paris, 1872. — Broadbent, William H., 
On Ingravescent Apoplexy, a Contribution to the Localization of 
Cerebral Lesions. Med. Chir. Trans., 59, 1876.— Gowers, William 
R, On "Athetosis" and Post-hemiplegic Disorders of Movement. 
Med. Chir. Trans., 59, 1876. — Lidell, J. A., A Treatise on Apo- 
plexy, Cerebral Haemorrhage, Cerebral Embolism, etc. New York, 
1873.— Thomson, W. H., Prophylaxis of Hemiplegia. New York 
Med. Record, 1878.— Sanders, Edward, A Study of Primary, Im- 
mediate, or Direct Haemorrhage into the Ventricles of the Brain. 
Am. Jour. Med. Sci., July and October, 1881. — Drozda, Jos. V., 
Statistische Studien iiber die Hemorrhagia cerebri. Wien. med. 
Presse, March 7, 1880. 

MENINGEAL HEMORRHAGE. 

When a vessel of the dura mater ruptures, the blood 
may escape either between the dura and the skull, or 
into the dura itself, between the layers of its fibers, or 
between it and layers of false membrane. The former 
is more frequently the result of an injury ; the latter is 
found in pachymeningitis hemorrhagica. The blood 
may also escape into the arachnoid space. This is not 
common, and, when it occurs, it can not be distinguished 
from haemorrhage following the rupture of one of the 
vessels of the pia mater. 



MENINGEAL EMMOREEAQE. 85 

^Etiology. — The causes of haemorrhage are blows 
and falls, bursting of aneurisms, other disease of blood- 
vessels, or thrombosis of sinuses. Kupture of aneurisms 
is the more common cause ; these may be either mili- 
ary or of considerable size. The effused blood may be 
but little in amount, or may cover a large extent, even 
dipping down into the sulci and fissures, and extending 
to both sides or penetrating into the ventricles. 

Pathological Anatomy. — The blood is usually 
poured out in such quantity that death follows before 
any change can take place in the clot ; occasionally 
death is delayed long enough to show that absorption 
has commenced, and in a very few instances the blood 
has been in such small quantity that it has been ab- 
sorbed, and, subsequently, the remains found in pig- 
mented spots on the membranes. In these cases there 
is a reasonable doubt whether the disease is not pachy- 
meningitis rather than meningeal haemorrhage. 

Symptoms. — The symptoms will vary according to 
the locality and extent of the haemorrhage. If there 
has been previous disease of blood-vessels, especially 
an aneurism of considerable size, there will have been 
corresponding symptoms preceding the attack. Many 
times these will be merely headache, lassitude, heavi- 
ness, vertigo. 

If the blood escapes suddenly in one gush, there 
will be a sudden and immediate loss of consciousness, 
and paralysis with slow pulse and stertorous respira- 
tion, and the patient may soon die. If the blood es- 
capes less rapidly, the loss of power will come on gradu- 
ally, and the patient may be able to walk across the 
room, or even farther, and call for assistance before 
sinking to the floor and losing consciousness. 

According to the locality of the haemorrhage, to the 
irritation excited by it, and perhaps other illy defined 
circumstances, there may be convulsions attending the 
attack. These may affect one or more limbs, may be 
universal, or may only affect certain cranial nerves. 



86 DISEASES OF THE BRAIN. 

Occasionally the patient recovers from the first at- 
tack of unconsciousness, and seems to be gaining until 
another, and, perhaps, several successive attacks ter- 
minate fatal] y. 

The symptoms are the result of a combination of 
local irritation, pressure, and anaemia of the brain. If 
the vessel is in the pia mater, the blood may be poured 
out with such violence and in such a direction as to tear 
up a portion of the cortex immediately adjacent. 

Diagnosis. — The peculiarities wherein meningeal 
haemorrhage differs from intra-cerebral haemorrhage 
are, the more frequent occurrence of convulsions and 
contraction in about a quarter of the cases ; the paraly- 
sis is less likely to be local, all the limbs suffer alike, 
and there is gradually diminishing power until total 
paralysis is reached, though sometimes there is hemi- 
plegia. The temperature follows very much the same 
course as in intra-cerebral haemorrhage. 

Prognosis. — Excepting in very rare instances, death 
is the invariable result. 

Treatment. — The treatment is the same as for in- 
tra-cerebral haemorrhage. 



CEREBRAL HEMORRHAGE. 

Cerebral haemorrhage and apoplexy are not syn- 
onymous terms. The latter is applied to all attacks 
wherein there is sudden loss of consciousness without 
convulsions, coma continuing for a longer or shorter 
time, ending in death, or partial or entire recovery. 
This may be the result of other causes than haemor- 
rhage, as congestion, or plugging of an artery by an 
embolus. 

^Etiology. — The amount of blood poured out de- 
pends upon the size of the blood-vessel ; also upon its 
situation. The white substance is much more easily 
torn up than the gray substance, and, when the blood 
bursts into one of the ventricles, there is much less 



CEREBRAL HEMORRHAGE. 87 

resistance to the bleeding than when it is confined by 
the cerebral substance. The form of the clot and of the 
cavity containing it depends upon the direction of the 
nerve-fibers among which the blood is poured out. 

The size of the clot may vary from that of a pin's 
head or of a pea to a clot occupying nearly the whole 
of a hemisphere. The largest clots are those where the 
haemorrhage begins in the corpus striatum or the optic 
thalamus, and extends into the white substance of the 
centrum ovale. The relations which the size of the clots 
and the frequency of haemorrhage bear to the cerebral 
circulation are considered by Duret. The anterior part 
of the caudate nucleus is supplied by nutrient branches 
arising from the anterior cerebral and anterior commu- 
nicating arteries. These are all small ; haemorrhages 
here are rare, and are usually small. The lenticular 
nucleus, and the anterior portion of the optic thala- 
mus, are supplied by arteries from the middle cere- 
bral, which is a large artery and nearly in line with the 
carotid ; the nutrient branches are comparatively large, 
and haemorrhages more frequently occur from these and 
are more likely to be copious. There are no large 
arteries running through the centrum ovale ; hence 
haemorrhages here are rare and of small extent. The 
posterior lobe is supplied with larger vessels from the 
posterior cerebral artery ; hence haemorrhages of consid- 
erable size may be found there. These are some of the 
more important and interesting conclusions at which 
Duret arrives. 

To Charcot and Bouchard belongs the credit of re- 
ferring cerebral haemorrhage to a periarteritis of the 
smaller arterioles, the external coats being first affected. 
There is an increase of nuclei of the lymphatic sheath ; 
the adventitia is also affected. The nuclei may be so 
crowded together that nothing else can be seen. Some- 
times, with less increase of nuclei, the adventitia may 
be thickened and may have longitudinal striae. Next, 
the muscular elements disappear without fatty degen- 



88 DISEASES OF TEE BRAIX. 

eration, the muscular markings on the artery becoming 
less distinct and fewer, until finally they disappear 
in limited regions ; then the artery may dilate, bulge 
out locally, and a minute aneurism is formed ; some- 
times only a fusiform swelling of the artery is seen. 
These miliary aneurisms may be very numerous through- 
out the brain, or a few in a limited region. They some- 
times seem to be quite large from the staining of the 
tissue immediately around them. 

They are found with most frequency in the corpus 
striatum and the optic thalamus, then in the pons Va- 
rolii, and the gray substance of the convolutions. These 
minute aneurisms bear an important relation to cerebral 
haemorhage, as in much the larger number of cases their 
rupture is the cause of the haemorrhage. 

Atheromatous degeneration of the larger arteries 
may favor a rupture by impairing the elasticity of the 
vessels. Increased strength in the action of the heart 
will also act as a cause of haemorrhage by sending the 
blood with increased force into the diseased vessels ; 
hence many cases occur while the patient is making 
violent effort ; but also many occur during sleep. 

While it is true that disease of the kidneys is found 
in many instances with cerebral haemorrhage, it is not 
as yet determined how frequent this association is. 

Some writers lay stress upon a vitiated state of the 
blood as a cause. This might affect the nutrition of 
the arteries, and so favor the disease. 

The condition of the brain is mentioned as another 
element in the production of haemorrhage. It is scarcely 
possible for periarteritis with many miliary aneurisms to 
exist without interfering with the nutrition of the brain, 
and doubtless many of the so-called premonitory symp- 
toms are thus produced ; but how much such change 
favors the occurrence of haemorrhage we have no means 
of estimating. Whether such changes are of the nature 
of softening, or of an increase of the interstitial tissue, 
is not yet known. Minute haemorrhages are sometimes 



CEREBRAL HMMORRHA GE. 89 

found around tumors in the brain ; generally they are 
very small, and cause no special symptoms. 

It is well to mention that cerebral haemorrhage oc- 
curs the more frequently after the age of forty years ; 
but it is also found in infancy ; it is perhaps more com- 
mon in winter than in summer, and in men than in 
women. 

Pathological Anatomy. — The changes in the brain 
and the blood-vessels predisposing to haemorrhage have 
been already described when speaking of the aetiology. 

The blood which escapes from the ruptured artery 
forces its way among the nerve-elements, separating 
some, tearing apart others, sometimes, if the clot is 
large, entirely isolating masses of cerebral tissue torn 
from their connections. At first the clot is dark red, 
uniform in consistency, resembling any other clot of 
blood. In a few hours the clot is somewhat less con- 
sistent, the watery constituents are absorbed, the color 
becomes lighter ; finally only a pale, yellowish-colored 
remnant with a few blood-crystals can be found. The 
nervous structures which have been torn and bruised 
undergo fatty degeneration, there is more or less soft- 
ening around the clot, the surrounding structures im- 
bibe the coloring-matter and are yellow, and granular 
corpuscles and fatty degeneration increase the extent 
of this colored zone. Inflammation may set in which 
will destroy extensive tracts of brain-substance and aid 
in bringing about the fatal termination. 

If the inflammation is slight and the patient sur- 
vives, the cerebral tissue immediately around the clot 
undergoes a fibrous change, the interstitial elements 
increase, and a cyst is formed, a firm wall separating 
the diseased from the healthy brain-substance. If the 
clot is small, there may be no cyst ; there is simply a 
small cicatrix of tough connective tissue. Sometimes 
there is no well-defined cyst- wall, the wall being soft 
and formed of a mixture of fibrous tissue and granular 
corpuscles in such proportions as not to have the firm- 



90 DISEASES OF THE BRAIN. 

ness above mentioned ; then this character of tissue 
passes imperceptibly into the normal cerebral structure. 

When the haemorrhage is situated so as to implicate 
the deeper layers of the cortex and the white substance 
beneath, and especially the anterior two thirds of the 
posterior limb of the internal capsule, a secondary de- 
generation appears after some weeks or months, follow- 
ing the nerve-fibers, through the crus cerebri, pons, and 
medulla, into the cord. 

According to Jaccoud, the clot remains soft and 
homogeneous during three to five days ; then absorp- 
tion continues to the tenth or twelfth day. After fifteen 
or twenty days the clot has contracted into a dense, 
solid mass of a yellowish color, quite different in ap- 
pearance from coagulated blood. The new formation 
around the clot begins generally on the seventh or 
ninth day ; toward the twentieth the cyst is formed, 
and by the thirtieth or fortieth the limiting membrane 
has become organized. 

Symptoms. — Premonitory symptoms will be recog- 
nized less frequently with some classes of patients than 
with others ; the less observing may give no heed to 
sensations or conditions which others may notice. 
Many patients have for a short time, or even days and 
weeks, preceding the haemorrhage, symptoms which are 
worthy of notice. These premonitory symptoms are 
very important as indications for a course of treatment 
to ward off the threatening attack, and even if in the 
majority of such cases no attack occurs, yet they should 
never be neglected. 

Among the symptoms which precede haemorrhage 
for several days or even weeks, the most common are 
those which show disturbance of the circulation or nu- 
trition of the brain ; among these the most frequent are 
sensorial disturbances. Oftentimes there have been 
long-continued symptoms of cerebral hyperaemia, head- 
ache, or sense of pressure in the head, dizziness, dis- 
turbance of eyesight, noises in the head, pricking, and 



CEREBRAL EMMORRHAGE. 91 

numbness, especially in the fingers, perhaps also in the 
feet, sometimes on one side, sometimes on both ; mental 
confusion, slight forgetfulness of words, loss of mem- 
ory, and change in disposition. Owing to impaired 
motor power or diminished sensation, there is a loss of 
delicacy in the touch, the character of the handwriting 
is changed, and there is awkwardness in using the 
hands. 

Sometimes, if severe and persistent, especially if uni- 
lateral, these symptoms are caused by slight haemor- 
rhages which may precede a more severe one. If there 
has been a haemorrhage with partial recovery, a recur- 
rence of these symptoms may be the warnings of re- 
newed danger. 

Ophthalmoscopic examination may occasionally 
show the presence of miliary aneurisms, dilatations of 
the retinal arteries, or slight retinal haemorrhages, and 
so be of value as indicating danger from the rupture of 
cerebral arteries. 

The symptoms attending the rupture of a blood- 
vessel in the brain will vary according to the locality of 
the lesion, the size of the vessel, and the rapidity and 
force with which the blood escapes. It is easily under- 
stood, therefore, that there may be great diversity in 
the initial symptoms as well as in the subsequent course 
of the case. 

The severest form of cerebral haemorrhage is that 
which may be called apoplectic. The patient suddenly 
loses control over himself, falls, if he is either sitting or 
standing, and soon entirely loses consciousness. At the 
same time reflex action of the limbs is abolished, and, 
unless there are convulsions, the patient lies limp and 
inert, simply breathing and swallowing if the substance 
is put far enough back in the fauces to excite the in- 
voluntary muscles of deglutition, though occasionally 
even these fail to act. The respiration may become 
noisy from the paralysis of the soft palate or from the 
accumulation of mucus in the bronchi ; at first the 



92 DISEASES OF TEE BRAIN. 

countenance is generally pale, but, if respiration is in- 
terfered with, it becomes dusky red. The cheeks flap 
back and forth with every respiration, passively follow- 
ing the current of air. The shortest time on record be- 
fore death under these circumstances is five minutes ; 
more frequently from half an hour to several hours 
elapse before the fatal termination. 

The attack, as above described, is far from common ; 
much more frequently there is a gradual development 
of the symptoms ; the patient is conscious that some- 
thing is amiss, and may try to rise from his chair, may 
be able to reach the bed or sofa, or, finding himself 
unable to hold articles in his hands, turns to speak to 
a friend and can not make himself understood. Soon 
he sinks powerless, and passes gradually into coma, 
which is not so extreme but that he can be aroused by 
a loud voice, or a powerful irritation may give rise to 
expressions of pain. Reflex movements generally per- 
sist. The unconsciousness may continue only a few 
minutes, or may persist much longer — even until death. 

During the unconscious stage the physician can 
often recognize that one side is paralyzed. The mouth 
is drawn to one side, the limbs on one side are stiff er 
than on the other, or half voluntary movements are 
made only with one side ; a strong irritation causes 
movements only on one side. But little can be learned 
from the condition of the pupils, as they are very vari- 
able ; but many times the eyes are turned continuously, 
both toward the same side, and the head is rotated with 
the face toward that side. This phenomenon is not of 
long duration ; it is seen in only a small proportion of 
patients, but, when present, it is valuable as indicating 
serious organic lesion, and may aid in determining its 
location. (See above, p. 44.) 

After the return of consciousness it will be noticed 
that there is hemiplegia, generally affecting both the 
arm and the leg. This paralysis may be complete, 
total loss of power ; cutaneous reflex action is usually 



CEREBRAL HEMORRHAGE. 93 

lost on the paralyzed side ; after a few hours or few- 
days power of motion returns, by degrees one act after 
another can be performed ; usually the legs gain the 
most rapidly, the more complicated action of the arms 
and hands being recovered later. Hughlings Jackson 
has formulated the proposition that the most instinct- 
ive, automatic actions are the first to return. 

The patient may continue to improve in his power 
of using his limbs for many months ; perhaps to a casual 
observer there is finally complete recovery ; but more 
frequently a stage is finally reached after which no fur- 
ther improvement can be expected ; the limbs on one 
side are weak ; certain motions can not be performed, 
or are executed only with difficulty and imperfectly ; 
there is hemi-paresis. 

The muscles of the face are often affected, and im- 
mediately after the attack the mouth is drawn to the 
opposite side, the naso -labial fold being more marked 
on that side. The nerve-fibers which supply the upper 
part of the face — the orbicularis palpebrarum, the front- 
al and corrugator supercilii muscles — usually are not 
affected. Nothnagel states that, when the tract of 
nerve-fibers passing along the base of the nucleus len- 
ticularis is involved, the above muscles are paralyzed. 
They may be paralyzed also if the lesion is in the lower 
part of the pons. 

Nothnagel also states that the muscles of the trunk 
are generally partially paralyzed. 

Speech may be interfered with ; the more frequent- 
ly from loss of power over the organs of speech, the 
muscles of the throat, and mouth and tongue. Only 
occasionally is there aphasia when the right side is af- 
fected. This is a much more frequent symptom in em- 
bolism. 

On the second to the fourth day after the attack 
symptoms may develop showing that there is an inflam- 
matory process around the clot. There is headache, 
confusion of thought, feverishness, contraction of the 



94 DISEASES OF TEE BRAIN. 

paralyzed limbs, sometimes slight convulsions. The 
duration of this stage is variable, from a few to several 
days ; sometimes these symptoms recur two or three 
times or more. 

Bourneville, considering the temperature, divides 
cases of cerebral haemorrhage into three clases : 1. Ful- 
gurant or multiple hemorrhages, death occurring in a 
very few hours, with initial depression of temperature. 
2. Cases ending in death in ten, fifteen, twenty hours, 
initial depression lasting only one to three hours or so, 
and subsequent rapid and considerable elevation of 
temperature. 3. Cases ending in death only after sev- 
eral days ; initial depression of short duration ; then a 
stationary period, continuing two to four days, with a 
primary slight elevation and subsequent oscillation 
about the normal ; finally an ascending period. Dur- 
ing the initial period of depression the pulse and res- 
piration are but little changed. If the patient is to 
recover, the ascending period is of brief duration, and 
the temperature does not rise very high, or it is entirely 
wanting. 

The above description refers to cases of severe cere- 
bral haemorrhage with loss of consciousness. In many 
cases there are no comatose symptoms. The patient 
more or less gradually loses power over one side, and 
falls with consciousness intact. The paralysis may be 
as complete, and the recovery of motion may occur in 
the same order, as in the other class of cases. After a 
first attack with the consciousness preserved, a second 
may occur soon in which that faculty is lost. 

Yet lighter attacks occur in which there is only a 
slight impairment of motion in only one or more limbs, 
or the attack may be confined to the face. There are 
all degrees of severity, from the very lightest to the 
most complete. 

Disturbance of sensation is not so common as that 
of motion. At first, indeed, sensation may be abolished, 
but it is more quickly recovered. Generally all varie- 



CEREBRAL HEMORRHAGE. 95 

ties of sensation are equally affected. Occasionally 
other parts than those whose motion is lost show 
diminution of sensation. Sometimes there is a persist- 
ent change of sensation, which is perhaps not always 
sought for. An object is perceived on both sides, but 
the impression is less acute on the affected side, or con- 
tact with the object excites also a peculiar tingling sen- 
sation besides the usual sense of touch. Sometimes 
there is increased sensitiveness to painful impressions. 

Ollivier has found in many cases a change in the 
urinary secretion after cerebral haemorrhage. There is 
first an increased secretion of urine, and albumen is 
found in it ; later sugar may be found. These changes 
occur almost immediately after the attack and continue 
only twelve to twenty-four hours ; they are not depend- 
ent upon the locality of the lesion. 

Cutaneous reflexes may remain diminished or lost 
on the side affected. Tendon reflex is often exagger- 
ated, especially after contractures have appeared. 

Dr. Sanders has written upon haemorrhages into the 
ventricles, separating such cases from both cerebral and 
meningeal haemorrhages. He has collected ninety-four 
cases of such primary haemorrhages, and considers 
their aetiology and pathology, which differ little from 
those of other cerebral haemorrhages. The diagnostic 
symptoms he mentions are suddenness of the attack 
without premonitory symptoms ; convulsions in the be- 
ginning, or later ; partial or complete coma, paralysis, 
contracture, dilated or contracted pupils. Death usu- 
ally occurs early, generally within twelve hours ; a few 
patients recover. The above symptoms are almost ex- 
actly those found in any case of severe cerebral haemor- 
rhage. A positive diagnosis is in many or most cases 
impossible. 

An explanation of tJie phenomena attending cere- 
bral haemorrhage will aid to a clearer understanding of 
the subject, and will be of value in determining treat- 
ment. 



96 DISEASES OF THE BRAIK 

Several explanations have been given of the initial 
loss of consciousness, the more important of which are, 
that by Niemeyer, who refers it to cerebral anaemia 
caused by compression of capillaries ; that by Trousseau 
and Jaccoud, and Jackson referring it to shock. The 
shock is direct on the side of the haemorrhage, is trans- 
mitted or reflex on the other. 

Nothnagel, after reviewing these and other theories, 
says: "We find ourselves, then, finally, obliged to ad- 
mit that the physiological relations of hemorrhagic 
apoplexy have not yet been made so clear as is com- 
monly believed." 

The most reasonable explanation seems to be that 
there is both shock with consequent exhaustion, and 
anaemia, not simply from compression of vessels, but 
also from reflex contraction. 

The paralysis, both of motion and sensation, is the 
result of the direct injury, of the shock, of the local or 
general anaemia from compression of the smaller ves- 
sels, the tearing across of others, of the oedema, the in- 
filtration of the surrounding cerebral substance with 
serum absorbed from the effused blood, this oedema 
also giving rise to anaemia. It is impossible to decide 
how large a share belongs to each of these elements in 
producing the patient's condition at the moment of re- 
covery of consciousness. The influence of shock and 
anaemia due to compression from the size of the clot 
pass off soonest. The anaemia due to the oedema will 
slowly disappear ; as the liquid parts of the clot are ab- 
sorbed, the uninjured nerve-fibers surrounding the clot 
gradually regain their function. Another probable 
source of improvement is found in the possibility that 
functions performed by the destroyed nerve-elements 
may be acquired by those of other parts of the brain, so 
that in time there seems to be very little paralysis re- 
maining. Also patients learn to use to the greatest ad- 
vantage the power which remains. One cause of delay 
in recovery may be found in the functional inertia of 



CEREBRAL HEMORRHAGE. 97 

long disused nerve-fibers, so that even after organic 
restoration there may still be a period of diminished 
functional activity. Finally, it is not unlikely that 
many injured nerve-elements heal, and nerve-fibers 
which have been ruptured or bruised may recover their 
organic integrity. After these processes of repair have 
gone to their utmost limits, there must still be a very 
large number of nerve-elements destroyed beyond pos- 
sibility of recovery. If, then, the haemorrhage is so situ- 
ated that these elements are necessary for perfect mo- 
tion and sensation, there will be a residuum of paralysis 
from which it is utterly useless to expect recovery. 

As a result of the imperfect healing of the torn 
nerve-fibers, a certain amount of paralysis remains per- 
manently. After a few months — two to four — a stiff- 
ness of the paralyzed limbs is noticeable ; there is a 
certain amount of contraction. The degree of the con- 
traction varies from a scarcely perceptible stiffness of 
the fingers to a firm closure of the hand, with flexion 
at the elbow and adduction of the arm. The upper ex- 
tremity is more frequently affected than the lower ; the 
lower is rarely affected alone. The flexor muscles are 
almost invariably the ones affected. At first the resist- 
ance of the contracted muscles is easily overcome, and 
during sleep the muscles relax spontaneously. On first 
waking, the hand is as supple as the other ; involuntary 
motions of stretching and yawning may be made by it 
in unison with the unparalyzed hand. Soon, however, 
as voluntary actions are performed, the contraction re- 
appears, to persist until the patient again sleeps. Pa- 
tients and their friends are often encouraged by this 
relaxation. It is far from being a favorable indication, 
and should never deceive the physician. Eventually 
the contraction may become persistent even during 
sleep. 

These contractures must be distinguished from those 
which occur earlier, either at the time of the attack 
and soon disappear, or a few days after, at about the 
1 



98 DISEASES OF TEE BRAIHT. 

time when inflammatory action arises around the clot. 
These also disappear within a short time. These latter 
varieties have been explained by supposing a direct 
irritation from the clot or from the subsequent inflam- 
matory processes. The first variety of contraction has 
been explained, by Charcot and others, by the presence 
of secondary degeneration in the lateral columns of the 
spinal cord. 

Associated movements, interesting to observe, are 
often seen in hemiplegic patients. After the partial re- 
turn of voluntary motion, if the patient tries to move 
the paralyzed limb, the unaffected limb will involun- 
tarily perform the same motion. It would seem that 
the motor impulse required to act on the partially par- 
alyzed muscles needs to be so great to overcome the 
resistance offered by the injured nerve-fibers that the 
lower motor centers on the opposite side are also set in 
action, the impulse crossing by the commissures to the 
unaffected side. 

In many cases of cerebral haemorrhage, after a par- 
tial recovery of motion, the effort to perform an action 
gives rise to irregular contraction of the muscles of the 
paralyzed limb which may resemble chorea, or when 
the will is not exercised there may be slow, irregular, or 
more rapid movements of the partially paralyzed mus- 
cles. These post-hemiplegic movements are well de- 
scribed by Gowers. They vary from a very slight mo- 
tion of the fingers to an almost constant motion of the 
whole arm, and even of the toes and leg. Among these 
movements is that which has been named athetosis by 
Hammond, which is more frequently seen after hemi- 
plegia occurring in infancy, but may also occur in 
adult life. 

More rarely there is sometimes seen a reflex tremor 
on the healthy side, occurring whenever the affected 
limb is moved. 

The mental faculties are almost always impaired 
after cerebral haemorrhage. In severe cases, of course, 



CEREBRAL HEMORRHAGE. 99 

these are at first entirely, or almost entirely, destroyed ; 
but even in light cases it is soon noticed that patients 
are very different in disposition and intellectual power. 
They are irritable and emotional, easily angry, or easily 
bursting into tears. One who has been very guarded 
in the use of language may, on slight provocation, or 
with no provocation, break out into oaths. The emo- 
tional excitement is almost exclusively associated with 
left hemiplegia. Memory may be more or less defect- 
ive. Even after almost perfect recovery some impair- 
ment of mental power may remain so as to render the 
patient unfit to carry on his business without assist- 
ance, and he may be so obstinate and suspicious as to 
render it advisable for him to give up all attempts to 
continue in business. 

The paralysis is usually confined to one side of the 
body, the face, arm, and leg being affected on the 
same side, but on the side opposite the seat of the 
haemorrhage. This is the common and regular form, 
a complete hemiplegia, and in these cases usually the 
upper branches of the facial nerve are not affected. 
There are, however, occasional irregular forms. What 
has been said in regard to localization of cerebral lesions 
will aid in diagnosticating the seat of the haemorrhage 
in these cases. Occasionally all four limbs are para- 
lyzed, either from multiple haemorrhages or from large 
effusions into the pons and medulla. Such cases are 
rapidly fatal. In a very few cases the paralysis has 
been found to be on the same side with the haemor- 
rhage. Sometimes the arms are affected on one side, 
the legs on the opposite side. Occasionally only the 
cranial nerves are affected, or only the arm is paralyzed. 

Acute bed-sores may form two to four days after 
the attack. They are situated on the paralyzed side, 
over the glutei muscles. Bed-sores may appear at a 
later period, being developed more gradually. They 
may occur on the knee or the heel, and are perhaps 
more frequent in elderly patients than in younger. 



100 DISEASES OF TEE BRAIN. 

An eruption of herpes has been known in several 
cases to follow cerebral haemorrhage, the eruption fol- 
lowing the distribution of certain nerves. The skin 
may undergo a thickening, amounting to hypertrophy. 
There is frequently more or less oedema of the para- 
lyzed hand, sometimes of the foot. The nutrition of 
the nails and hair may also be interfered with on the 
affected side. 

An acute inflammation of the joints has been ob- 
served following cerebral haemorrhage. This is devel- 
oped first fifteen days or a month after the attack, 
about the time when the late contraction appears. The 
swelling, redness, and articular pains are sometimes as 
marked as in acute articular rheumatism. The affec- 
tion of the joints is limited to the paralyzed limbs. 

The general nutrition of the paralyzed muscles does 
not seriously suffer in adults, and there is no degenera- 
tion. When cerebral haemorrhage occurs in children 
there may be subsequent retarded development. Two 
cases have been reported in which there was muscular 
atrophy, with secondary degeneration of the cells of the 
anterior cornu.* As a rule, also, the electrical reaction 
of both nerves and muscles for both the faradic and 
galvanic currents is unchanged. Once in a while there 
may be a slight diminution, occasionally a slight in- 
crease in the irritability. 

Diagnosis. — Haemorrhage into the substance of the 
brain is to be distinguished from meningeal haemor- 
rhage, from thrombosis and embolism of a cerebral ar- 
tery. The diagnosis from these will be considered un- 
der those divisions. 

While the patient is unconscious there may arise a 
doubt whether the coma is due to haemorrhage or to 
poisoning by alcohol, opium, or whether it is a case of 
uraemic poisoning. 

The odor of alcohol may be recognized in the breath, 

* See Pitres in " Arch, de Physiol.," 1876, p. 657 ; and " Charcot's 
Lectures," t. i, p. 55. 



CEREBRAL HEMORRHAGE. 101 

or, if there is vomiting, in the vomitus ; but this does 
not exclude cerebral haemorrhage. If, on examination, 
unilateral symptoms appear, and especially if there is 
conjugate deviation of the eyes and rotation of the 
head to the same side to which the eyes are turned, 
the diagnosis is made easier. The course of the tem- 
perature, at first lowered for an hour or so, then rising, 
will indicate haemorrhage. 

The diagnosis from opium poisoning may be made, 
in part by the above-mentioned symptoms, also by the 
more gradual advent and increase of the coma. The 
fact of there being convulsions would exclude opium 
poisoning. The state of the pupils could not be de- 
pended upon, as they may be contracted in haemor- 
rhage, and are occasionally dilated in opium poisoning, 
especially just before death. 

Uraemic poisoning is at times equally difficult to 
recognize. The unilateral character of the symptoms 
will generally aid here, though not always. The pres- 
ence of albumen in the urine will not necessarily ex- 
clude haemorrhage, for in many cases of Bright's dis- 
ease this accident occurs ; yet, from the history of the 
case and the condition of the patient, a probable opinion 
may be formed. 

Epileptic convulsions may be very slight and the 
succeeding coma deep, so as to give rise to doubt 
whether there has not been cerebral haemorrhage. Oc- 
casionally in epilepsy there is conjugate deviation of 
the eyes and rotation of the head ; also once in a while 
the attack is unilateral, and there remains a temporary 
paralysis afterward. The history of previous similar 
attacks, with rapid recovery from the paralysis, may 
clear up the doubt ; but if this is wanting, it may be 
impossible to come to a satisfactory conclusion. These 
cases of epilepsy are, however, very rare, and generally 
the diagnosis is not difficult. 

Hemiplegia may be assumed with a desire to de- 
ceive, as in a suit for damages after an injury. The ig- 



102 DISEASES OF TEE BRAIN: 

norance of such persons usually gives rise to inconsist- 
encies in their account of the symptoms. The pre- 
tended contraction is not like the real. Associated 
movements on the healthy side do not occur when 
an effort is made to move the affected limb. Almost 
always the true hemiplegic will endeavor to aid the 
disabled hand with the well hand, or the body will be 
inclined to act as a fulcrum to help raise the arm. The 
pretender does not do this. 

Jastrowitz* states that pressing the greater saphe- 
nous nerve about a hand's breadth above the internal 
condyle of the femur causes the testicle to rise on the 
healthy side, but has no effect on the hemiplegic side. 
It has been said that other reflex acts also do not take 
place on the hemiplegic side. When the skin is ex- 
posed there is no goose-flesh ; tickling the nostril does 
not produce sneezing ; touching the eyelashes does not 
cause winking. If there should be a difference be- 
tween the two sides in these respects, a diagnosis as 
between narcotic poisoning or simulation and cere- 
bral lesion could be made ; but whether that lesion is a 
haemorrhage or some other must depend on other data. 

During the earlier hours or days the attempt to lo- 
calize the lesion will often be useless. It is not until 
the effects of the shock and pressure of the clot have 
passed away that the more permanent symptoms can 
be recognized, and these must chiefly be considered in 
localizing the lesion. 

Prognosis. — During the comatose stage, soon after 
the attack, it is impossible to form any opinion as to 
how severe the attack will prove ; but the longer this 
stage continues the less favorable the prognosis, and if 
it lasts beyond forty-eight hours there is very little 
probability of recovery. If the attack is accompanied 
with severe convulsions, which are not due to epilepsy, 
the prognosis is the more serious, as the convulsions 
attend large haemorrhages — those which burst into the 

* "Berlin, kl. WoeDenschrifV 1875, No. 31. 



CEREBRAL HAEMORRHAGE. 103 

ventricles and those which are situated in the pons and 
medulla. The occurrence of Cheyne-Stokes respiration 
is of unfavorable augury. 

There is a form of attack which has been called in- 
gravescent, which is always fatal. With prodromic 
symptoms, coma gradually comes on, or there is a sud- 
den loss of consciousness of short duration, after which 
intelligence is partially or entirely recovered, to be 
gradually lost again ; the coma steadily deepens, and 
paralysis becomes more and more complete. The symp- 
toms steadily increase in severity until the patient lies 
helpless and senseless, simply breathing, not to be 
aroused by any form of irritation. These cases are 
hopeless ; the haemorrhage occurs from one of the 
larger vessels between the lenticular nucleus and the 
external capsule, the nerve-fibers are pressed apart, not 
many are torn asunder ; hence the earlier symptoms are 
slight. 

After the initial depression of temperature, if the 
patient survives and the temperature steadily rises, the 
prognosis is unfavorable. If there is a slight rise and 
then a stationary period varying but little from 100°, 
after which another rise of temperature, then the prog- 
nosis is unfavorable again. If the temperature does 
not rise a second time, or falls to normal, the prognosis 
is favorable. When polyuria, albuminuria, and glyco- 
suria exist in a very marked degree, the prognosis is 
grave. 

During the period of inflammatory reaction the 
prognosis depends upon the intensity of the fever and 
attendant symptoms. 

Acute bed-sores appearing shortly after the attack 
are extremely unfavorable, and are almost certain to be 
followed by death. 

If the patient survives, a complete recovery is rarely 
to be expected. Trousseau considers that if the motor 
power returns in the leg first, before the arm, the prog- 
nosis is more favorable, at least for retention of mental 



104 DISEASES OF THE BEAIR. 

power. Recovery of motion may progress slowly for 
an indefinite period. If the late contraction appears, 
there is little or no chance of further improvement, and, 
in regard to disappearance of the contraction, the prog- 
nosis is absolutely unfavorable. 

A second attack may occur in any one who has suf- 
fered from a cerebral haemorrhage. If there is evident 
disease of the arteries, Bright's disease, or retinal haem- 
orrhages, this is more likely to occur. Also, if the pa- 
tient be past middle life, there is more probability of 
another attack. After an attack, a return of prodromic 
symptoms would indicate renewed danger. 

Treatment. — When the physician first sees a pa- 
tient attacked with cerebral haemorrhage, the injury 
has probably been done ; in most cases the blood has 
ceased to escape from the ruptured vessel. Trousseau 
advocates very strongly to let the patient alone ; others 
advise bleeding (Jaccoud, Huguenin) under certain con- 
ditions. If the patient is hearty, robust, with a strong- 
ly acting and healthy heart, and is evidently suffering 
from too great blood-pressure in the cranial cavity, 
they advocate general bleeding as the most effectual 
means of relieving this excessive blood - pressure. 
Bleeding is not indicated where the pulse is weak, if 
the patient is aged or feeble, or if there is heart dis- 
ease, or when the coma has been of short duration and 
consciousness has returned. Practically, very few cases 
are suitable for bleeding under these conditions. In by 
far the larger number of cases nothing can be done ex- 
cept to place the patient on a bed with the head rather 
elevated, loosen all the clothing, and wait. As perfect 
quiet as possible should be maintained, the patient not 
moved, and fed with the simplest diet : if previously in 
full health and well nourished, it will be no disadvan- 
tage to feed sparingly ; if in poor health and ill nour- 
ished, the feeding should be more abundant. If the 
heart's action is feeble and there is evident lack of vi- 
tality, stimulants, at first external, afterward, if neces- 



CEREBRAL HEMORRHAGE. 105 

sary, internal, should be used. After return of con- 
sciousness no special medical treatment is needed until 
the period of inflammatory reaction, when cold to the 
head, a laxative to open the bowels, and, if there is 
much headache, chloral, or some preparation of opium 
or belladonna, to relieve the pain. Occasionally, dry 
caps to the back of the neck or local bleeding may be 
called for. Ergot, by mouth or subcutaneously, may 
be used to diminish the danger of renewed haemorrhage. 

After the danger from inflammatory reaction is 
passed, many times there will be necessity for medical 
treatment. The patient should be kept quiet, secluded, 
in a well ventilated apartment, with proper regard for 
all hygienic influences ; should have a plain, unstimu- 
lating diet, not half starved, but should receive suffi- 
cient food. After a few weeks the nutrition of the 
muscles would be benefited by systematic rubbing, 
massage ; later, after five or six weeks, electricity may 
be used. If proper care is exercised in not using too 
strong a current, and not continuing the application 
too long, this agent may be used without danger, and 
even with benefit, earlier than many authors advise it. 
The galvanic current, using from three or four to twelve 
cells, may be applied to the head — one electrode on the 
upper cervical vertebral, the other over the mastoid 
process, or just below — or one pole on each side of the 
head, the positive on the same side with the haemor- 
rhage. Great care is to be taken not to suddenly inter- 
rupt the current, to use it only one minute, or at most 
two ; to use a current which will not cause dizziness. 
Whether any benefit is ever obtained by this use of the 
galvanic current is extremely doubtful, and it is men- 
tioned entirely upon the authority of several European 
observers. 

The application of the induced or faradic current 
locally is attended with less risk, and is many times of 
positive benefit. One pole may be placed on some in- 
different point, and the other passed lightly over the 



106 DISEASES OF THE BRAIN. 

different muscles, the current being graduated so as to 
cause the muscles to contract slightly without pain. 
The weakest current which wall do this is strong enough. 
It is not necessary to move the limbs. The application 
should not exceed half a minute to a minute for each 
muscle, and this not continuously, but one muscle after 
another may be exercised for a few seconds, and then 
the limb be gone over again. This application will have 
the advantage of sustaining the nutrition of the mus- 
cles ; also, the muscles would not fall into a state of 
sluggishness from simple inertia. Sometimes it will be 
found that electricity does harm ; then, of course, it 
should be immediately omitted. 

During the period of gradual recovery little can be 
done in the way of medication ; absorption and resti- 
tution of structure and function advance slowly. For- 
merly, and even now, strychnia has been given very 
freely. It is not of sufficient benefit to offset the 
danger arising from its use in these cases. The absorb- 
ent properties of iodide of potassium render that drug 
acceptable, but with care not to disturb the stomach. 
Occasionally, especially in syphilitic cases, mercury has 
seemed of value. After the occurrence of late contrac- 
tion, little or no improvement need be expected ; though 
some cases are reported of benefit from electricity in 
these cases, I have never seen any. 

As pneumonia and bronchitis are especially liable to 
attack the lung on the affected side, especial care should 
be taken after an attack to avoid exposing the patient. 

After an attack the patient is anxious to guard 
against its recurrence. All measures necessary to sus- 
tain perfect health are in place — the avoidance of what- 
ever will produce an increase of pressure in the cerebral 
blood-vessel, a quiet, composed life, with recreation and 
amusement sufficient for healthy action of the mind 
without excitement. If in active business, the activity 
should be moderated. 



CHAPTER VI. 

OCCLUSION OF CEREBRAL ARTERIES. 

Lancereattx, E., De la thrombose et de l'embolie cerebrales 
considerees principalement dans leurs rapports avec le ramollisse- 
ment du cerveau. Paris, 1862. — Gelpke, Ottomar, Vergleichende 
Zusammenstellung der Symptome von Hirnapoplexie und Embo- 
lie der Hirnarterien. Archiv der Heilkunde, 1875. — Meissner, 
Berichte liber Embolien und Thrombosen. Schmidt's Jahrb., 109, 
117, 131. 

The cerebral arteries may be suddenly plugged by 
the lodgment of a portion of a clot or other foreign 
body brought from a distance, an embolus, or gradu- 
ally by the growth of a tumor, by the thickening of the 
walls of the artery, or by the coagulation of the blood 
at the point where the obstruction occurs. The sudden 
stopping of an artery by a clot brought from a distance 
is called embolism ; the plugging by a clot formed on 
the spot is called thrombosis. 

EMBOLISM. 

^Etiology. — The emboli may arise in the pulmonary 
veins, or the left side of the heart, or in any of the ves- 
sels between the heart and the point where they lodge. 
Much the more frequently they arise in the heart as 
the products of acute or chronic endocarditis. Warty 
growths form on the valves, are torn off and carried 
into the circulation, or a blood-clot forms in the heart 
and portions are broken off. Aneurisms of the aorta 
are sometimes the source whence the fragments of clot 



108 DISEASES OF THE BRAIN. 

arise. Disease of the lungs, as pneumonia or phthisis, 
cancer or embolism, or thrombosis of the pulmonary- 
vessels, may serve as the point of origin of an embolus 
which may be carried by the pulmonary vein to the 
heart, and thence to the brain. Any diseases, then, 
which may give rise to endocarditis or the above pul- 
monary affections are remote causes of embolism. 

Pathological Anatomy. — It is not necessary to 
describe the changes which the embolus undergoes, 
except to say that in rare cases it is broken down and 
absorbed. 

Immediately after the occlusion of an artery the 
blood from the veins flows back into the distal branches 
of the obstructed artery, and there is more or less sta- 
sis. In the brain it is very rare that the anastomoses 
are sufficient to maintain an active circulation, hence 
the region which depends upon these branches for its 
nutrition suffers from lack of healthy blood ; the walls 
of the vessels also suffer and allow the blood to escape. 
The cerebral tissue is infiltrated with serum, the blood 
undergoes change, and its coloring-matter is diffused 
through the part, and gives a red or yellowish tint to 
the broken-down nervous tissues. 

The nervous elements, being deprived of healthy 
blood, lose their vitality, soften, undergo fatty degen- 
eration, and are reduced to a semi-fluid pulp. If the 
region affected is small, this may be absorbed, a cica- 
trix is formed, and the spot of softening may finally 
disappear, but more frequently a cyst remains filled 
with serum and crossed by bands of connective tissue. 

The softening does not show itself immediately ; it 
is perceptible only thirty-six to forty-eight hours after 
the occlusion of an artery. 

Owing to the direction in which the different arteries 
are given off from their main trunks, emboli are much 
the more frequently carried into the left carotid, and 
are generally lodged in the middle cerebral artery or 
one of its branches. Duret has described the distribu- 



EMBOLISM. 109 

tion of softening which belong to the various branches 
of the cerebral arteries. 

Symptoms. — Generally without warning, the patient 
is attacked with loss of consciousness and entire loss of 
power. There may be, for a few minutes, headache or 
vertigo, but the attack is usually sudden and complete. 
The loss of consciousness is of less duration than in 
haemorrhage, and may be only momentary. It is fre- 
quently accompanied with general epileptiform con- 
vulsions. Vomiting and delirium are sometimes pres- 
ent. Occasionally paralysis is the first symptom. 
Consciousness is not always lost ; there may be merely 
confusion of thought. 

After recovery of consciousness and voluntary power 
it will be found that the patient has paralysis of one 
side. Usually the face and limbs of the side opposite 
the lesion are affected, and as the left middle cerebral 
artery is much the more frequently the seat of embo- 
lism, the right side is usually the one affected. 

The temperature is slightly lowered immediately 
after an attack, but quickly rises, and, if the case 
proves fatal within three or four days, the rise of tem- 
perature is almost unbroken. If the patient lives from 
five to fifteen days, the temperature is irregular. If 
the attack is not fatal, the temperature falls to very 
nearly or quite to the normal after three or four days. 

After the earlier stage of the disease the symptoms 
are essentially the same as in haemorrhage. Contrac- 
tion of the limbs is seen less frequently than after 
haemorrhage, yet is essentially the same when it oc- 
curs. The intellectual disturbance is rather less 
marked. 

Disturbance of the faculty of speech is not uncom- 
mon in embolism, and when the right side is paralyzed 
there is almost always aphasia. 

Occasionally the aphasia is the only symptom pres- 
ent ; there is no loss of consciousness, nor paralysis. 
Some of these cases are due to embolism of small ar- 



HO DISEASES OF THE BRAIN. 

teries, some are due to disturbance of circulation de- 
pending upon other causes. 

The embolus may lodge in an artery, stop the blood- 
current for a few minutes, and then, by a change of its 
position, the blood may be able to pass it in sufficient 
quantity to restore the nutrition of the brain. If the 
embolus is then broken up and absorbed, there may be 
no further trouble ; or if it adheres firmly to the wall 
of the vessel, there may be no further trouble. If, 
however, its position is again changed, it may plug the 
vessel finally, and then the symptoms become perma- 
nent. 

When other than the middle cerebral artery is 
plugged by an embolus, the symptoms will vary ac- 
cording to the portion of the brain affected. 

Diagnosis. — The diagnosis is almost exclusively be- 
tween haemorrhage and embolism. The question as to 
the diagnosis of thrombosis is reserved till the latter 
affection has been considered. 

It is frequently impossible to be certain whether 
there has been embolism or haemorrhage ; but, by a 
careful consideration of all the symptoms and other 
circumstances, it will generally be possible to form a 
satisfactory diagnosis. 

Gelpke has given a valuable review of the diagnostic 
points between apoplexy and embolism. The first is 
age ; apoplexy is by far the more frequent after fifty— 
embolism before fifty. More than sixty per cent (near- 
ly or quite seventy per cent) of the cases of apoplexy 
occur after fifty ; more than sixty per cent of the cases 
of embolism occur before fifty. 

In haemorrhage there is disease of arteries ; so this 
is found most frequently in connection with Bright's 
disease or where there are atheromatous changes. 
Embolism occurs most where there is cardiac valv- 
ular disease. In haemorrhage there may be premoni- 
tory symptoms; in embolism the attack occurs gen- 
erally without warning. When there seem to be pre- 



EMBOLISM. Ill 

monitory symptoms, they are rather due to independent 
attacks. 

The symptoms which are found during and immedi- 
ately after the attack may be very much alike, yet 
there are slight differences which may aid in diagnosis. 
Both embolism and haemorrhage are frequently accom- 
panied with hemiplegia ; but in embolism it is almost 
always on the right side; in haemorrhage on either 
side : so left hemiplegia would rather point to haemor- 
rhage ; right hemiplegia not necessarily to embolism. 
Epileptic attacks at the time of seizure rather indi- 
cate embolism. The muscular paralysis is greater 
in embolism than in haemorrhage. Aphasia, agraphia, 
and amimia depend upon changes in or near the 
island of Keil, and are the more frequent in embo- 
lism. Ataxic loss of speech depends upon lesion of 
the corpus striatum, and is the more common in haem- 
orrhage. In embolism the symptoms of cerebral press- 
ure are wanting, as diminished frequency of pulse, 
stertorous respiration, vomiting, contracted pupil, and 
strabismus. 

After the attack the mental powers are more likely 
to be affected in haemorrhage, especially the emotional 
faculties. There is also more likely to be reaction ; and 
a return of function, if it occurs, is slower in haemor- 
rhage. 

The discovery of an embolism in other arteries, as 
radial, femoral, etc., would aid in establishing a diag- 
nosis. 

The temperature may also assist. In embolism, dur- 
ing the first few hours, the initial depression of tem- 
perature below normal is wanting or very slight ; in 
haemorrhage it is much more marked. In embolism, 
after a temporary rise, the temperature returns to the 
normal with irregular exacerbations or evening eleva- 
tions; in haemorrhage it returns less quickly to the 
normal unless a second haemorrhage occurs. After the 
stationary period the rise of temperature is slower in 



112 DISEASES OF THE BRAIN. 

embolism, and generally does not attain so high a 
figure as in haemorrhage. 

Exceptional cases of embolism occur where the vari- 
ation of temperature more nearly resembles that found 
in haemorrhage. 

If there is complete recovery within a few days after 
an attack of complete hemiplegia, there probably was 
not haemorrhage. 

Prognosis. — "At the outset of and during the pri- 
mary attack, no prognosis can be given as to the prob- 
able course of the case, except that its severity is likely 
to be proportionate to the extension and severity of the 
primary symptoms. If the paralytic symptoms disap- 
pear after a brief period, there will be no reason to fear 
the presence of serious structural disease, but the chance 
of future attacks can not be excluded." ("Ziems. 
Cyclop.") 

Severe cases are more serious than severe cases of 
haemorrhage, and more likely to prove fatal. 

When the vertebral or basilar artery is plugged, the 
prognosis must necessarily be very unfavorable. 

Treatment. — Unless the patient is very feeble and 
requires slight stimulation, the less done during the 
first few days the better. Blood-letting and depressing 
measures are decidedly contra-indicated. If there arise 
indications of cerebral irritation from collateral hyper- 
emia, the bowels should be freely acted upon and the 
head kept cool. 

The subsequent treatment may be the same as in 
cerebral haemorrhage. 

THROMBOSIS OF CEREBRAL ARTERIES. 

JEtiology. — The causes of thrombosis of cerebral 
arteries are to be found either in the vessels themselves, 
in the composition of the blood, or in the diminished 
action of the heart. The walls of the vessels may be- 
come roughened from disease, as in arteritis obliterans, 
whether syphilitic or not, and also in case of atheroma, 



THROMBOSIS OF CEREBRAL ARTERIES. 113 

especially if the inner epithelial layer is broken ; the 
vessel may be contracted through a small extent of its 
length, and thus the blood-current be retarded. The 
disease of the walls of the vessels as found in old age 
interferes with their normal elasticity, and so favors 
retardation and coagulation of the blood. Disease or 
weakness of the heart may also cause the blood to flow 
less rapidly, and so favor the formation of a thrombus ; 
or the blood may coagulate more readily than usual, as 
in certain febrile diseases. Disease of arteries and fee- 
bleness of heart's action are found combined in old age ; 
consequently thrombosis is most common in advanced 
life ; very few cases occur below forty years of age ; 
most patients are over sixty. 

Pathological Anatomy. — When the thrombus 
fills an artery whose branches are not connected by an- 
astomoses with other arterial supply, the brain, deprived 
of blood, must necessarily undergo the same degenera- 
tion as is found in embolism. Often the smaller end 
arteries are stopped up, and then small spots of soften- 
ing will be found throughout the brain ; this is most 
commonly seen in the white substance. The cavities 
thus formed may vary in size from a sixteenth of an 
inch in diameter to an inch or more ; if numerous, they 
average an eighth to a quarter of an inch ; they are 
crossed by bands of connective tissue containing blood- 
vessels ; there may be a new growth of vessels if inflam- 
mation has set in. The walls of these cavities usually 
contain granular corpuscles. If recent, the nerve-fibers 
around the border of the cavity may show enlargement 
of axis- cylinders and other inflammatory changes. 

Sometimes, instead of a cavity, cicatricial tissue 
forms and a hard nodule is left. 

Symptoms. — As the arteries are usually closed grad- 
ually, there is a less sudden onset of the symptoms than 
is found in embolism. For a variable length of time 
the patient has had more or less discomfort in the head 
— pain or dizziness — memory may be less strong, the 



114 DISEASES OF THE BRAIX. 

patient may show signs of mental disturbance or tem- 
porary loss of consciousness, which are referred to old 
age, or there may be actual insanity ; sometimes tem- 
porary loss of power or abnormal sensations in the 
limbs, which soon pass away, but again appear, show 
that there is serious disturbance of the cerebral circula- 
tion. If the region of the pons and cerebral peduncles 
are affected, individual cranial nerves may be more or 
less paralyzed. There may be a numbness and tingling 
in the limbs on one or both sides, or a slowly increas- 
ing paralysis may be the result of gradual loss of 
power in the motor tracts. 

After these undefined, perhaps doubtful and confus- 
ing, symptoms have continued, it may be for months, 
there may occur an apoplectic attack ; the vessel which 
had been only partially obliterated is suddenly entirely 
plugged ; then the symptoms of embolism follow. 

Diagnosis. — Thrombosis and embolism differ in the 
above premonitory stage, which perhaps may be de- 
scribed more properly as the gradual development of 
the symptoms. 

It may be almost impossible to decide whether there 
is a thrombus or a haemorrhage when the artery is final- 
ly plugged suddenly. A number of independent attacks 
of paralysis, of unconsciousness, or of dizziness, from 
which the patient soon recovers, followed by the finally 
permanent attack ; the advance of the symptoms by 
stages, as it were, with intervals when there was no ad- 
vance — would point to a thrombus rather than a haemor- 
rhage. A preceding or accompanying acute disease, as 
pneumonia, or a great general feebleness, should cause 
a suspicion of thrombosis. Age, disease of arteries 
and of kidneys, would be as significant of one as the 
other. 

After the apoplectic attack the diagnosis of thrombus 
would be made from the same peculiarities as are found 
in embolism. 

When there are several attacks of unconsciousness, 



THROMBOSIS OF CEREBRAL ARTERIES. 115 

or of paralysis, or of dizziness, there may be a question 
as to whether the patient is suffering from epilepsy. It 
should be kept in mind that epilepsy rarely originates 
in old age ; a careful study of the phenomena attending 
the attack will show a lack of resemblance with epilep- 
sy ; bromide of potassium is more likely to aggravate 
the symptoms in thrombosis, but relieves them in epi- 
lepsy. 

The diagnosis of locality must be made from com- 
parison of symptoms with facts which have already 
been given, only remembering that the symptoms due 
to pressure would be absent. 

Peognosis. — The physician must judge of the dan- 
ger to life by the course and severity of the symptoms. 
The more extended the signs of disturbance, the longer 
the unconsciousness continues, the more certain the le- 
sion can be located in the mesencephalon, the more 
serious must be the prognosis. 

Treatment.— When a diagnosis of thrombosis can 
be made, the treatment should be tonic and mildly 
stimulating ; when it is impossible to certainly exclude 
haemorrhage, it is not desirable to give stimulants free- 
ly ; and in very doubtful cases it may be better to do 
nothing more than to put the patient in as favorable 
hygienic conditions as possible, insure quiet, rest, and 
absence of excitement. If the patient is young, and 
has had syphilis, a course of iodide and mercury would 
certainly be appropriate. 

After an apoplectic attack the treatment would be 
the same as under similar circumstances arising from 
other causes. 



CHAPTER VII. 

TUMORS OF THE BRAIN. 

Ladame, Paul, Symptomatologie und Diagnostik der Hirnge- 
schwiilste. 1865. — Macabian, Jean Firmin, Quelques considera- 
tions sur les tumeurs du cervelet. Paris, 1869. — Bramwell, By- 
ron, Clinical Lectures on Intra-cranial Tumors. Edinburgh Med. 
Jour., 1881.— Nothnagel, H., Topische Diagnostik der Gehirn- 
krankheiten. Berlin, 1879.— Bernhardt, M., Beitrage zur Symp- 
tomatologie und Diagnostik der Hirngeschwiilste. Berlin, 1881. 
— Klebs, E., Beitrage zur Geschwulstlehre — Hirngeschwiilste. 
Prag. Vierteljschr., cxxxiii. — Jackson, J. H., Diagnosis of Tumor 
of Brain. Med. Times and Gaz., August 9, 1873. 

Pathological Anatomy. — Many of the tumors 
which are found within the skull are not properly tu- 
mors of the brain — that is, do not take their rise from 
the cerebral tissue, but arise from the meninges or the 
blood-vessels ; some arise from the bones of the skull. 
As all these are revealed to us by the symptoms pro- 
duced by their influence upon the brain, it is proper 
and most convenient to include all under the term "tu- 
mors of the brain." 

It is unnecessary to give details of the histology of 
the different kinds of tumors which may be found in 
the brain or connected with its envelopes. Tubercle, 
cancer, gummata, sarcoma, osseous growths, myxoma, 
and lipoma do not differ essentially from the same 
growths found elsewhere. Glioma, psammoma, and 
cholesteatomata are among the tumors which more 
peculiarly belong to the brain. The first, glioma, is 
simply a development of the normal neuroglia with 
sometimes the admixture of more or less fibrous tissue. 



TUMORS OF TEE BRAIN. H7 

They vary in consistency according as cells or fibrous 
tissue predominate. 

Psammoma consist in the formation of grannies of 
calcareous substance infiltrated into the cellular tissue. 
There may be also hyperplasia of the pineal gland or 
of the pituitary gland. 

^Etiology. — Certain tumors, as tubercle, cancer, or 
syphilitic gummata, must be referred to a constitutional 
diathesis. Blows and falls upon the head are often the 
direct cause of the development of abnormal growths. 
The cause of a large number of tumors can not be cer- 
tainly discovered. 

Symptoms. — There are certain symptoms which may 
be called general, or common, which are found in almost 
every case of intercranial tumor without reference to its 
locality ; other symptoms depend upon the situation of 
the tumor and aid in locating it. The latter symptoms 
are important as well in assisting to form a diagnosis of 
the presence of a tumor, the common or general symp- 
toms oftentimes not being definite enough for that pur- 
pose. 

Sometimes a tumor gives rise to so few symptoms, 
or they are so slight, that no notice is taken of them, 
or there may be no symptoms. This is more likely to 
occur where the tumor is quite small, where it is situ- 
ated in certain parts (anterior or posterior) of the white 
substance, and where it is very slow in growth. 

The symptoms depend upon the immediate effect of 
the tumor upon the nervous structures, destruction or 
irritation ; upon its effect at a distance, irritation and 
pressure ; and upon the inflammatory or other changes 
which it excites in the cerebral substance, more espe- 
cially in its vicinity. 

The general symptoms are, in most instances, due to 
the remoter effects or to the less direct changes excited 
by the new growth. The most common symptom is 
headache ; this is also usually one of the first, and is 
characterized by its persistency and the severity of the 



118 DISEASES OF THE BRAIN. 

paroxysms. Remissions, sometimes even intermissions, 
may occur, in which the headache is replaced by a feel- 
ing of slight discomfort in the head. In some cases a 
slight noise or the least motion brings on an attack. 
When severe, remedial agents have no power to allevi- 
ate the pain. The more rapid the growth of the tumor, 
the more severe and persistent is the headache. 

Dizziness, or vertigo, is a frequent symptom in the 
early stages of the disease. Nausea and vomiting are 
very frequently present, and may be very obstinate. 
These are rather the more frequent when the posterior 
part of the hemispheres or the cerebellum is affected. 

Various mental disturbances belong among the ear- 
lier symptoms, such as change of disposition, a pleasant, 
good-natured patient becoming cross and irritable, or 
one who has been careless and unconcerned taking upon 
himself the opposite qualities ; one who has been open 
and frank becoming silent, morose, and suspicious. 
Memory fails, power of mental application is lost, and 
business cares and responsibilities become a burden. 
None of these changes are sufficient to rank as insanity ; 
there is simply slight mental disturbance, which may 
be perceived even before the headache shows itself. 

When all these symptoms are found together, per- 
sisting in spite of treatment or only partially relieved 
thereby, the presence of cerebral tumor is almost cer- 
tain. The diagnosis is yet more certain when any of 
the following symptoms are also present : 

There may be a general failure of muscular strength, 
no definite paralysis of any set of muscles, but a sim- 
ple and increasing enfeeblement. When the cerebral 
disease is secondary to disease elsewhere, as tubercular 
or cancerous, it may be impossible to decide how much 
this weakness is due to the constitutional state, or to 
the local disease in the brain. 

Spasms and convulsions are sometimes so general or 
indefinite that they are to be considered* as general 
symptoms. They are, however, probably dependent 



TUMORS OF TEE BRAIN. 119 

upon an irritation of the cortical gray substance, either 
direct or remote, either primary or reflex. Spasms 
localized in one or a few groups of muscles belong to 
the localizing symptoms. 

There is rarely pain in the limbs, but various abnor- 
mal sensations, as numbness, formication, pricking, and 
tingling, are not uncommon ; sometimes there is great 
diminution of ordinary sensations. 

Disturbances of special senses, excepting eyesight, 
are not common ; deafness and anosmia are rare ; taste is 
lost only or chiefly when the mesencephalon is affected. 
Diplopia, amblyopia, amaurosis, and hemianopsia are 
not rare ; they belong more especially to localizing 
symptoms, and have been more or less fully considered 
already. 

Disturbance of speech, rotatory movements, com- 
pelled movements forward or backward, conjugate de- 
viation of the eyes and head, also belong to localizing 
symptoms, and have been considered in previous pages. 

Optic neuritis is very frequently one of the second- 
ary or remote symptoms of cerebral tumor, and, when 
present, may be of great value in forming a diagnosis. 
In every case of cerebral disturbance the ophthalmo- 
scope should be used, whether there is disturbance of 
vision or not. The neuritis may exist unsuspected by 
the patient. 

Other signs of ill health may be present, as emaci- 
ation, anorexia, pyrexia, constipation, retention or in- 
continence of urine, disturbance of circulation or of 
respiration. 

The symptoms which enable one to localize the tu- 
mor have been mentioned already ; they are also im- 
portant as showing the presence of organic change in 
the brain, but other symptoms indicate the nature of 
that change. 

The temperature of the body is not very often raised, 
but several observations of the temperature of the head 
show that there is an increase of surface-heat on the 



120 DISEASES OF THE BRAW. 

side where the tumor is, especially immediately over it. 
This branch of inquiry has not been pursued far enough 
as yet to decide whether the degree of elevation has 
any relation to the nature of the tumor or its rapidity 
of growth. Great care is necessary in taking these ob- 
servations to guard against errors. 

The course of the disease varies greatly according 
to the rate of increase and the situation of the new 
growth. It is hardly necessary to say that a rapidly 
growing tumor will cause many more severe symptoms 
than one which increases in size more slowly. Inflam- 
mation or congestion around a tumor may give rise to a 
sudden outbreak of symptoms, and their rapid increase 
in severity. This may subside, and then a remission 
would succeed. 

As a rule, with occasional remissions, or even inter- 
missions, in the symptoms, there is a steady advance ; 
the headache may at length diminish in intensity, per- 
haps because of destruction of nerve-fibers, the con- 
vulsions may cease because the motor areas are de- 
stroyed, but with the apparent improvement the mental 
powers will be found to have diminished, the paralysis 
to have increased, the patient is more helpless ; while 
suffering less, he has evidently lost ground. 

At length there is complete hemiplegia, or possibly 
paralysis of the entire body, the bladder and rectum 
are affected as in other cases of hemiplegia, and bed- 
sores form ; it becomes constantly more difficult to give 
the proper nourishment, and the patient dies exhausted. 

Many times, however, the fatal termination is more 
speedily reached, the respiration or heart's action is 
interfered with, or pulmonary complications set in, 
and the patient soon dies. 

The duration is very variable ; cancer, tubercle, and 
syphilitic growths are rapid in their course ; glioma 
may slowly advance for years, with many intermis- 
sions. 

There are many questions which it would be inter- 



TUMORS OF THE BRAIN. 121 

esting to consider, but the object is simply to lead to a 
correct diagnosis, and indicate the most rational treat- 
ment. 

Diagnosis. — The diagnosis of tumors of the brain 
from other cerebral affections is by no means always 
easy. Tubercular meningitis may sometimes closely 
resemble tumor. It is more common in children than 
adults, while tumors are more frequent in adults. 

Chronic thickening of the membranes, especially if 
occurring at the base, so as to involve the cranial nerves, 
may give rise to exactly the same symptoms as a tu- 
mor. Such thickening is more frequently seen as the 
effect of a syphilitic taint. 

Abscess of the brain is usually accompanied with less' 
headache, is less likely to have ocular symptoms, to 
cause vomiting and vertigo, and is more frequently the 
result of an affection of the ears. 

Apoplexy and embolism may generally be distin- 
guished from tumor by the suddenness with which the 
symptoms occur, and the peculiarities of the first at- 
tack. Nevertheless, in rare cases, tumors have re- 
mained comparatively latent for an indefinite period 
of time, and then manifested their presence by an at- 
tack closely resembling apoplexy. A careful study of 
the symptoms attending the onset, and the previous 
state of the patient's health, especially whether any of 
the general symptoms indicating tumor existed, also an 
examination of the heart and kidneys, would assist ma- 
terially to a correct diagnosis. 

An obstinate and persistent headache, such as some- 
times occurs at puberty, may give rise to anxious fore- 
bodings, lest it should be significant of serious brain 
trouble ; much more would such anxiety arise if the 
headache were attended with attacks of vomiting. A 
careful study of the whole history of the case, and a 
careful examination of the patient, will aid more than 
anything in forming a diagnosis ; but it may be neces- 
sary to wait for time to settle the question. 



122 DISEASES OF TEE BRAIN. 

Prognosis. — The result is almost invariably fatal, 
the patient being finally worn out by bed-sores, or de- 
bilitated by insufficient nourishment from the difficulty 
of swallowing or the continuous vomiting. Sometimes 
the fatal termination occurs during an epileptic attack, 
or in an attack of apoplexy. It is almost impossible 
to judge with any degree of certainty in regard to the 
duration of life. 

Possibly, if the growth is syphilitic and has not at- 
tained too large a size, there may be recovery ; though 
recovery itself might throw some doubt upon the cor- 
rectness of the diagnosis. 

Treatment. — The treatment of cerebral tumors may 
be included under two heads — treatment designed to 
cure the patient, and that intended to relieve certain 
symptoms. Where there has been a previous syphi- 
litic infection, it is advisable to pursue an active course 
of antisyphilitic treatment — iodide of potassium with- 
out hesitation in sufficient doses to produce a marked 
effect within a comparatively short time, and mercury. 
Even where syphilis is not proved, a course of iodide 
of potassium may be of great benefit. 

Counter-irritation to the head and neck has been 
recommended. It is extremely doubtful if the growth 
of a tumor is influenced thereby, though some of the 
unpleasant symptoms may be mitigated. 

To fulfill the second indication — if convulsions of an 
epileptiform character are frequent — one of the bro- 
mides in large doses may give more or less relief. 
As headache is one of the most distressing symptoms, 
patients are imperious in their demands to be relieved 
therefrom ; if apparently not very severe, milder meas- 
ures may first be tried, as counter-irritation to the neck, 
bromide of potassium, cannabis Indica, caffein. If the 
pain is severe, probably nothing will relieve it except 
one of the preparations of opium. There should be 
no hesitation in using this drug in such doses as to give 
relief. Often a comparatively small dose will accom- 



TUMORS OF THE BRAIN. 123 

plish the purpose ; it is well occasionally to intermit 
its use to learn whether the headache may not have 
ceased ; at such times a weak solution of quinine may 
very conveniently take the place of morphine by the 
mouth, or water may be used for subcutaneous injec- 
tion. 

The vomiting which accompanies cerebral tumor is 
often very obstinate and intractable. It should be 
treated according to the condition of the patient. 
Counter-irritation to the head and neck or over the 
stomach should not be omitted when other means fail. 
Ice to the head and neck may be useful. If other 
means do not succeed, morphia may control it. 

Of course, the conditions of the patient, which re- 
quire special treatment, as cystitis, bed-sores, etc., 
should receive the necessary care. 



CHAPTER VIII. 

CEREBRAL ABSCESS. 

Kohler, A., Ein Beitrag zur Lehre von Gehirnabscess. 
Schmidt's Jahrb., 183, 1879.— Meyer, E., Zur Pathologie des 
Hirnabscesses. Zurich, 1867. — N aether, R., Die metastatischen 
Hirnabscesse nach primaren Lungenherden. Deut. Arch. kl. Med., 
xxxiv, 1883.— Thompson, H., Case of Otitis, Cerebral Abscess, etc. 
Med. Times and Gaz., March 29, 1878.— Fenger, Christian, On 
Opening and Drainage of Abscess Cavities in the Brain. Am. 
Jour, of the Med. Sci., July, 1884. 

ABSCESS OF THE BRAIN. 

^Etiology. — The causes of cerebral abscess are almost 
always evident. One of the most common, perhaps the 
most common cause, is inflammation of the ear. When 
the otitis affects the bone, there is always danger that 
the disease may extend to the brain ; either the bone is 
perforated, and so the dura and pia mater exposed to 
direct irritation, or, as is more frequent, the inflamma- 
tion is transmitted through the foramina or veins. In 
all cases of otorrhcea in children, the danger of this 
complication should be kept in mind. 

Injuries to the head, whether attended with fract- 
ure of the bone or not, are frequent causes of cerebral 
abscess. 

Disease of the bone, caries, from whatever cause, 
may give rise to abscess. An abscess may form about 
a haemorrhage, or the infarctus due to an embolism or 
thrombus. 

Pyaemia may be a cause ; erysipelas and acute dis- 



ABSCESS OF TEE BRAIN. 125 

Pathological Anatomy. — The division has been 
made of red and yellow inflammation : the distinction 
depends npon the relative amount of blood or pus con- 
tained in the diseased tissue. Abscesses may be en- 
cysted, i. e., surrounded by a close, firm layer of new- 
formed tissue ; or they may have no containing wall, 
the pus, mixed with debris of the cerebral substance, 
being in direct contact with the softened, partly broken- 
down tissues. 

The abscess may vary in size from very small to in- 
clude nearly a whole hemisphere. 

The histological changes which the tissues pass 
through consist in a cloudy swelling of the elements, 
a gradual breaking up into granular debris and trans- 
formation into granular corpuscles, and increase of 
connective-tissue fibers and cells around the focus, 
when a capsule is formed. 

The nervous elements themselves are destroyed by 
fatty or granular degeneration, sometimes preceded by 
swelling, or hypertrophy of axis-cylinders and nerve- 
cells. 

Around the abscess there may be very great oedema 
of the cerebral tissue, and sometimes congestion, some- 
times an ansemic condition. 

Symptoms. — The symptoms are quite similar to 
those attending tumor of the brain. Headache is one 
of the most common. This is severe, and generally 
continuous. If not intense, there is at least a feeling 
of discomfort, of pressure, of lightness, or dizziness. 

Mental confusion, disturbed memory, sometimes 
delirium, show how seriously the higher intellectual 
faculties are implicated. 

Nausea and vomiting may be among the earlier 
symptoms, and, if very persistent soon after an injury 
to the head, or if they set in during an attack of otor- 
rhea, should give reason to suspect abscess. 

Paralysis and disturbance of sensation other than 
headache are not very common ; sometimes the motor 



126 DISEASES OF TEE BRAIK 

centers, or motor tracts, are affected, and then local 
paralysis or hemiplegia may be noticed. 

Convulsions are rather common ; they may be local 
only ; or, as is more frequent, beginning as local, they 
become general ; they may, from their commencement, 
be clearly epileptic in character. The increased irrita- 
bility of the motor centers caused by the inflammation 
fully explains their occurrence. 

When pressure increases, there may be the corre- 
sponding symptoms — retarded pulse, stupor, stertorous 
respiration, etc. 

Sometimes meningitis is one of the results of the 
injury or disease causing the abscess ; then the symp- 
toms of cerebral meningitis may predominate. 

Either the abscess runs a rapid course, terminating 
fatally within a few days or weeks, or a period of re- 
mission may set in ; the abscess may remain latent for 
an indefinite time. When thus latent, it is probably 
always encysted. During this time of remission or 
latency, some of the symptoms may persist in a dimin- 
ished degree of intensity. In other cases there is no 
acute initial stage ; the abscess from the beginning runs 
a chronic or concealed course. At length an active in- 
flammation starts up around the abscess, and all the 
symptoms are aggravated, the patient becomes paralyzed 
and comatose, and soon dies ; or the cedema around the 
focus of disease increases suddenly and rapidly, and 
so the patient dies. 

The abscess may rupture into the lateral ventricles, 
giving rise to sudden aggravation of the symptoms ; 
general convulsions are usually excited ; there may be 
loss of consciousness. 

Yery rarely a local meningitis is excited, the mem- 
branes adhere, the bone is perforated, and the abscess 
is discharged externally. The evacuation may be fol- 
lowed by recovery. Occasionally recovery results with- 
out discharge of the contents. 

Diagnosis. — Cerebral abscesses have many symp- 



ABSCESS OF THE BRAIN. 127 

toms common to cerebral tumors : headache, vomiting, 
dizziness, the symptoms of pressure, are common to 
both affections. 

The preceding otorrhcea, or the history of an in- 
jury not long before the cerebral symptoms are devel- 
oped, would indicate an abscess. If a tumor follows 
an injury, a much longer interval must elapse before it 
shows its presence. Local paralysis and hemiplegia 
are more common with tumors, excepting toward the 
later stages. A rapid increase in severity of symptoms 
after a period of remission, amounting perhaps almost 
to intermission, is indicative of abscess. Local convul- 
sions, followed sometimes by general convulsions, are 
met in tumors of the cortex ; general convulsions, with- 
out preceding local spasms, are more common in ab- 
scess. The diagnosis between abscess and tumor may, 
however, frequently be impossible. 

Meningitis is accompanied by higher fever, by more 
marked cutaneous hyperesthesia, less frequently by 
convulsions. Yet the diagnosis may be very difficult 
or impossible, especially as meningitis may be pro- 
duced by the same causes as abscess, and the two dis- 
eases may co-exist, one as the cause of the other, or both 
depending upon the same cause. 

The diagnosis of locality is less easy than in other 
forms of cerebral disease. The same general principles 
should guide in a decision, but, as a rule, the data upon 
which to found an opinion are fewer and less trust- 
worthy. After an injury the abscess may be on the 
opposite side, the brain having suffered there by contre 
coup. . 

Prognosis. — Recovery is the exception — so rare that 
little account need be taken of such cases. A remis- 
sion may excite strong hopes of cure, but there is the 
constant danger of a return of the symptoms in a more 
aggravated form. 

Treatment. — After an encephalitis has gone so far 
as to give rise to an abscess, medical skill is compara- 



128 DISEASES OF THE BRAIK 

tively powerless. The treatment must then consist in 
quiet, rest, and avoidance of excitement. Counter-irri- 
tation might be used if there is doubt as to the abscess 
having been formed ; mercury, by mouth or inunction, 
is strongly advised. Cold may be applied continu- 
ously. 

More benefit can be hoped from the use of precau- 
tions to prevent the formation of an abscess. Otorrhcea 
should never be neglected, especially in children ; an 
effort should be made to cure the local disease. 

When there has been severe injury to the head, rest 
and quiet should be maintained for a while, and, if 
there is attendant headache, the enforced quiet should 
be kept up till that disappears ; during this time the 
diet should be sufficient, but light, easily digested, and 
unstimulating ; cold applied continuously, and leeches 
may be used. Free action of the bowels by cathartics. 

The question of trephining in injuries to the skull 
belongs to surgery. 



DISEASES OF THE SPINAL CORD. 



CHAPTER IX. 

ANATOMY, PHYSIOLOGY, AND GENERAL SYMPTOM- 
ATOLOGY. 

Bramwell, Byrom, The Diseases of the Spinal Cord. New 
York, Wm. Wood & Co., 1882.— Althaus, Julius, On Sclerosis of 
the Spinal Cord. New York, 1885.— Schuster, Diagnostik der 
Riickenmarks-Krankheiten. Berlin, 1884. — Charcot, J. M., Lect- 
ures on the Diseases of the Nervous System. 2d Series. New Syden- 
ham Soc, 1881. Lectures on the Localization of Cerebral and 
Spinal Disease. Ibid., 1883.— Leyden, E., Klinik der Riicken- 
marks-Krankheiten. Berlin, 1874. — Page, H. W., Injuries of the 
Spine and Spinal Cord. London, 1883. — Vulpian, A., Maladies 
de la moelle. Paris, 1879. — Buzzard, Thomas, Clinical Lecture 
on Diseases of the Nervous System. Philadelphia, 1882.— Drum- 
mond, David, Diseases of the Brain and Spinal Cord. London, 
1883.— Gowers, W. R, The Diagnosis of Diseases of the Spinal 
Cord. Philadelphia, 1884.— Seguln, E. C, The Localization of 
Diseases in the Spinal Cord. Opera Minora. New York, 1884, 
p. 436 ; also p. 283.— Schiefferdecker, Beitrage zur Kenntniss 
des Faserverlaufs im Riickenmark. Arch. f. mikroskopische 
Anatomie, Bd. 10, H. 4, p. 471.— Hollis, W. A., Researches into 
the Histology of the Central Gray Substance of the Spinal Cord 
and Medulla Oblongata. Journal of Anatomy and Physiol., 
July, 1883.— Ranney, A. L., The Applied Anatomy of the Nerv- 
ous System. New York, 1881. — Ibid., The Architecture of the 
Spinal Cord and its Relations to Medicine. New York Med. Jour. , 
1884. — Adamkiewiez, A., Die Blutgefasse des menschlichen 
Ruckenmarkes. Stzsbrct. der k. Akad. der Wiss., Wien, lxxxiv, 
1881, lxxxv, 1882. See, also, Ross, Erb, in Ziemssen's Cyclopaedia, 
vol. xiii, Leyden, Drummond, etc. — Brown-Sequard, C. E., Lect- 
ures on the Physiology and Pathology of the Central Nervous 
System. Philadelphia, 1860. — Stirling, William, On the Reflex 
Functions of the Spinal Cord. Edinburgh Med. Jour., April, 
1876, p. 914.— Purser, J. M., On the Anatomy and Physiology 
of the White Tracts of the Spinal Cord. Dublin Jour, of Med. 



132 DISEASES OF TEE SPINAL CORD. 

Scl, 1878.— Ott, J., and Smith, R. M., The Paths of Conduc- 
tion of Sensory and Motor Impulses in the Cervical Segment of 
the Spinal Cord. Am. Jour. Med. Sci., Oct., 1879, p. 438.— 
Starr, M. Allen, Localization of the Functions of the Spinal 
Cord. Am. Jour, of Neurol, and Psych., Aug. and Nov., 1884, 
p. 443. — Ibid., The Sensory Tract in the Central Nervous System. 
Jour, of Nervous and Ment. Diseases, July, 1884, p. 327. — See, 
also, Ross, Erb, etc. 

ANATOMY. 

The membranes of the spinal cord are usually de- 
scribed as three — the dura mater, arachnoid, and pia 
mater. The dura mater is double, the outer portion 
forming a periosteum for the vertebrae ; the inner layer 
is connected with the outer by loose connective tissue, 
containing fat and blood-vessels. This inner layer is 
the portion usually referred to in speaking of the dura 
mater. 

Opinions differ as to the arachnoid : some authors 
consider it as forming part of the other two membranes, 
while others regard it as a distinct membrane. 

The pia mater is closely adherent to the cord, and 
through it run the nutrient vessels for the cord. It 
sends processes into the fissures of the cord ; it sur- 
rounds the nerve-roots in their course from the cord to 
the dura mater. From the pia mater, on each side, 
arises the ligamentum denticulatum, which keeps the 
spinal cord in the center of the spinal canal. It runs 
the whole length of the cord, and stays it, by means of 
twenty to twenty-three teeth-like processes, to the dura 
mater. 

The space between the pia mater and dura mater is 
filled with the cerebro-spinal fluid, which is contained 
in a very loose, wide-meshed connective tissue. 

The spinal cord is then suspended in the cerebro- 
spinal fluid by means of many processes of the pia 
mater, by the nerve-roots, and the posterior septa. This 
suspension is so contrived that the influence of jars 
and shocks may be reduced as much as possible. 




B ^ 

Fig. 16. — Diagram illustrating the relations of the nerve-fiber tracts in the spinal cord. 
The section is supposed to be taken transversely through the lower part of the 
cervical enlargement (slightly modified from Flechsig by Hammond) : 

A. Anterior Median Fissure. 

B. Posterior Median Fissure. 

C. Intermediate Fissure. 

D. Anterior Gray Cornu. 

E. Posterior Gray Cornu. 

F. Gray Commissure, with Central Canal. 

G. Uncrossed Pyramidal Tract (Flechsig), or Column of Turck. 

H. Fundamental Part of the Anterior Column (Anterior Koot-Zones of Charcot and his 

pupils). 

I. Anterior Part of Lateral Column. 

K. Crossed Pyramidal Tract of Lateral Column. 

L. Direct Tract from Lateral Column to Cerebellum. 

M. Column of Burdach, Posterior Root-Zones of Charcot and his pupils. 

N. Column of Goll. 



The posterior columns of descriptive anatomy include the fields M and N extending on 
the surface from B to R. The antero-lateral columns extend on the surface from 
R to A. Their anterior division includes the fields G and H ; their lateral division, 
the fields K, L, and I. 



ANATOMY. 133 

The anastomoses between the arteries on the surface 
of the cord are very free, especially in the cervical and 
lumbar portions, least so in the dorsal region. The 
smaller arteries in the interior of the cord anastomose 
quite freely. The central gray substance and internal 
parts of the cornua are supplied chiefly by one set of 
vessels ; the white substance and outer part of the cor- 
nua by another. The gray substance has a larger blood- 
supply than the white. 

The cord extends lower in women than in men — in 
the former reaching the second lumbar vertebra, in the 
latter only the first. In men the proportion between 
the cord, the vertebral column, and the length of the 
body, is 1 : 1*62 : 3*76 ; in women the same proportion is 
1:1-56: 3'58. 

The gray matter is arranged around a central cavity 
called the central canal, which extends throughout the 
length of the cord. Two processes project forward, one 
on either side, called the anterior coma; two similar 
processes project backward, one on either side, called 
the posterior cornu. The gray matter is relatively 
larger, and the cornua are thicker, in the cervical and 
lumbar enlargements, and smaller in the dorsal region. 
In the anterior cornua are large nerve-cells, with many 
processes arranged approximatively in groups — the in- 
ternal, the anterior, the antero-lateral, the postero-lat- 
eral, and central. Lockhart Clarke gave the name trac- 
tus intermedio lateralis to a group of cells correspond- 
ing to the postero-lateral group mentioned above. At 
the junction of the posterior cornua with the central 
gray matter there is found also, at certain levels, a 
group of cells of very nearly equal size ; these cells 
are nearly spherical, with only one process. Scattered 
among these are smaller cells, usually fusiform in shape ; 
this group is called the internal vesicular columns by 
Clarke ; many authors name it Clarke's column. 

The posterior cornua are formed of two varieties of 
structure, the spongy portion near the central gray sub- 



134 DISEASES OF TEE SPINAL COED. 

stance, the gelatinous substance posterior to the former, 
and running forward on each side of it, having the 
form of an irregular crescent. A few large nerve-cells, 
with many processes, are found scattered through the 
gelatinous substance, especially along its outer border. 
The nerve-cells in the spongy portion are rarely of 
large size. In the posterior cornua are found also some 
of the smallest cells belonging to the spinal cord. The 
opposite sides are connected in front of the central canal 
by nerve-fibers forming the anterior or white commis- 
sure ; behind the central canal is a commissure formed 
of gray matter — the posterior or gray commissure. 

The white substance of the spinal cord is divided 
into two lateral halves by an anterior and posterior 
fissure. The anterior fissure is the better marked, and 
extends about one third through the cord to the white 
commissure. The posterior fissure is not quite so deep 
as the anterior, and is less well marked ; sometimes, in- 
deed, its position is only indicated by a small blood- 
vessel in a narrow band of connective tissue. 

Each half of the white substance is roughly divided 
by the anterior and posterior cornua into three col- 
umns — the anterior, lateral, and posterior. The ante- 
rior and lateral are frequently spoken of together as 
the antero-lateral column. The posterior column is 
divided into two portions by a septum of connective 
tissue, usually containing blood-vessels, situated at a 
variable distance exterior to the posterior fissure. The 
column between this septum and the posterior fissure is 
called the internal posterior column, or more frequently 
the column of Goll. The nerve-fibers in this column 
are on an average the smallest in the cord. This divis- 
ion of the posterior column is seen throughout the 
length of the cord, but the internal portion gradually 
diminishes in size downward, and in the lumbar region 
mere traces of it are found. The portion on each side 
between the lateral septum and the posterior cornu is 
called the external posterior column, or more frequently 



ANATOMY. 135 

the external radical column or posterior root-zone, or 
column of Burdach. The anterior column is also di- 
vided into two portions, but with less definiteness than 
the posterior column. There is a narrow band along 
the edge of the anterior fissure, which, physiologically 
and pathologically, is distinct from the rest of the an- 
terior column. This is called the direct pyramidal col- 
umn, or column of Tiirck ; this column can be traced 
upward to the crus cerebri of the same side without 
decussating. In the lateral column there is also a dis- 
tinct group of fibers called the lateral pyramidal tract, 
which occupies about the center of the lateral column, 
in the cervical region, having the cerebellar fibers along 
its outside. In the lower dorsal and lumbar regions 
these cerebellar fibers gradually diminish in thickness 
until they disappear ; hence the pyramidal fibers come to 
the surface. The white substance around the extremi- 
ties of the anterior cornua may be called the anterior 
root-zones. 

The pyramidal fibers in both the anterior columns 
and the lateral columns can be traced from the brain. 
Arising from the motor centers in the brain, they pass 
through the anterior two thirds of the posterior seg- 
ment of the internal capsule, the middle of the crusta 
(basis) of the crus cerebri, through the pyramidal re- 
gion of the pons and medulla to the anterior pyramids. 
In the anterior pyramids the fibers intended for the 
lateral columns decussate and pass down the opposite 
half of the cord ; the direct fibers do not decussate, but 
pass down the anterior columns on the same side, next 
the anterior fissure. 

It may be mentioned here that the divisions above 
described are differentiated physiologically, pathologi- 
cally, and in some cases anatomically ; and also by the 
fact that the nerve-fibers in the different portions ac- 
quire a medullary sheath at different periods of devel- 
opment, as has been demonstrated by Flechsig, Ross, 
Charcot, Parrot, and others. 



136 DISEASES OF THE SPIRAL CORD. 

The anterior nerve-roots enter the cord opposite the 
anterior cornna. Before entering the cord, the roots 
split np into small bundles of nerve-fibers, which are 
distributed laterally over a space corresponding in ex- 
tent with the width of the anterior cornua. These 
fibers pass directly through the white substance into 
the gray matter, or take a longitudinal direction for a 
short distance, and then pass into the anterior cornua. 
The posterior nerve-roots enter the cord near together 
on a vertical line; some of the fibers pass directly 
into the posterior cornua, but most of them pass into 
the external radical column, and enter the posterior 
cornua at different levels. Some fibers pass directly into 
the vesicular columns, and some of these pass forward 
to one of the groups of anterior cells. Some of the 
fibers of the white columns run long distances before 
entering the gray substance ; such are the fibers in the 
anterior and lateral pyramidal columns, the columns of 
Goll, and the cerebellar fibers. Other fibers run only a 
short distance, serving as commissural fibers for the 
gray substance at different levels. 

PHYSIOLOGY OF THE SPINAL CORD. 

The spinal cord is not a simple organ, as must be 
realized from the brief account of its anatomy ; the 
functions it is intended to fulfill are many, and its 
physiology, consequently, is complicated. We are jus- 
tified, then, in considering the cord, not as one simple 
organ, but as a series of organs having somewhat dif- 
ferent functions. The cord may be divided, theoreti- 
cally, into as many sections as there are pairs of nerves 
arising therefrom, and each section be regarded as a 
distinct unit connected with its fellows by commissural 
fibers ; or it may be viewed as several different nerve- 
entities arranged side by side longitudinally, each indi- 
vidual connected with the others by transverse commis- 
sures. Sometimes one view will be most convenient for 
understanding phenomena, and sometimes the other. • 



PHYSIOLOGY OF TEE SPINAL CORD. 137 

The groups of nerve-cells in the gray substance act 
as centers of nervous influence, more or less independ- 
ent. Those in the anterior cornua are connected with 
the nerve-fibers of the anterior roots, and serve as media 
by which motor impulses are communicated through 
the nerves to the muscles, whether those impulses come 
from the brain or from the sensory nerves of the poste- 
rior roots — that is, whether they are volitional or reflex. 
Attempts have been made to assign different nerve- 
groups to certain muscles ; while this can be roughly 
approximated, as yet much that has been written in 
regard to such a division of function is theoretical. 

Among these cells are to be found also centers of 
nutrition, trophic centers for both nerves and muscles. 
It is not yet settled whether distinct nerve-cells have 
this function, or whether it is exercised by the motor 
cells ; as Ferrier expresses the thought, "We have as 
units of external function certain nerve- centers, cen- 
trifugal nerves, and peripheral organs, muscular, gland- 
ular, and their adjuncts. In union they exhibit certain 
vital properties and reactions which we call normal. 
. . . But dissolve the unity, and the tissues are left 
to their own powers of nutrition," and various forms of 
degeneration are seen. 

The posterior cornua are known to belong to the 
sensory portion of the cord. Their cells are in some 
way concerned in transmitting sensory impressions to 
the brain, or in transferring them into reflex phenome- 
na ; perhaps they intercept some impressions and utiliz- 
ing them for stimulating vital processes, do not permit 
such impressions to reach the brain unless they are un- 
usually strong. The sense of pain is conveyed specially 
by the posterior gray substance, and a very small sec- 
tion of this is sufficient to transmit pain ; when the pos- 
terior columns are diseased, probably some of the ordi- 
nary sensations pass through the gray substance by 
unusual paths ; hence, perhaps, the delay sometimes 
noticed in conduction of sensation. 



138 DISEASES OF TEE SPIXAL COED. 

Sensations, whether of pain or the ordinary sensa- 
tions, after entering the cord by the posterior nerve- 
roots, soon pass to the opposite side and then ascend 
to the brain. 

The white columns are commissural ; some connect 
the brain with different groups of cells, others connect 
these groups of cells with one another. 

The pyramidal tracts connect the motor areas of the 
brain with the groups of cells in the anterior cornua — 
the lateral pyramidal tracts decussating in the anterior 
pyramids, the direct passing down without decussation. 
The fibers which govern the respiratory muscles seem to 
pass down in the lateral columns without decussation. 

The anterior root-zones are commissural, and are con- 
cerned specially in reflex actions, and, perhaps, in co- 
ordinating the action of nerve-cells at different levels. 

The posterior columns are sensory. The external 
radical columns, columns of Burdach, are probably 
chiefly commissural, and are employed for co-ordina- 
tion of the sensory impressions and translation of these 
into reflex or semi-reflex acts. Many of the fibers of 
the posterior nerve-roots pass upward or downward in 
these before they enter the posterior cornua. 

The fibers of the columns of Goll pass upward 
toward the brain ; their mode of termination and func- 
tion are not known. 

The posterior columns in one or both of its divisions 
transmit the ordinary sensations — touch, temperature, 
pressure, etc. — but not the sensation of pain. 

The direct cerebellar tract is composed of ascending 
fibers, and is said to be connected with Clarke's vesicu- 
lar column at the root of the posterior cornua. Its 
function is not known. 

GENERAL SYMPTOMATOLOGY. 

It will be convenient to mention the groups of symp- 
toms which indicate lesion of certain regions of the 
spinal cord. 



GENERAL SYMPTOMATOLOGY. 139 

Total paralysis of motion, sensation not being af- 
fected, points to lesion of the antero-lateral columns 
and anterior cornua. If the paralysis is unilateral, it 
will be on the same side with the lesion. 

If, in disease of the cord, there is simply paralysis, 
without marked wasting or change of electrical reaction 
in the muscles, provided time enough has elapsed since 
its origin, neither the anterior cornua nor the nerve- 
roots at the level, whence arise the nerves supplying 
the paralyzed muscles, can be affected. 

If besides paralysis there is spasm, contracture, and 
increased reflex action in the affected limbs, without 
pain, the lateral columns are affected. The anterior 
columns may be diseased too, but the symptoms would 
not necessarily indicate it. The spasmodic phenomena 
and increase of reflex action follow, whether the lesion 
of the lateral columns is primary or secondary. 

If, in disease of the spinal cord, with the paralysis, 
there is also wasting of the paralyzed muscles and loss 
or great diminution of reaction to the faradic current, 
still more if there is increased reaction to the galvanic 
current, with reversal of qualitative reaction (degen- 
erative reaction), the lesion is either in the anterior 
nerve-roots or in the anterior cornu. It is rare to 
have the anterior nerve-roots affected as they pass 
through the anterior columns, unless the lesion is trau- 
matic in its origin. Unless the anterior cornu is dis- 
eased over a considerable length of the cord, the paraly- 
sis is local, and the muscles supplied by nerves arising 
below the seat of the lesion are healthy. When ouly a 
few muscles are affected, especially if they form a group 
which physiologically act together, the disease may be 
limited to a very small area. 

Ferrier ("The Localization of Atrophic Paralyses," 
"Brain," vol. iv, 1881-82, p. 226) gives the muscles sup- 
plied by the different nerves of the brachial and lumbar 
plexuses. Some of the muscles mentioned are supplied 
by fibers from more than one nerve ; only that nerve 



140 DISEASES OF TEE SPINAL CORD. 

giving the largest proportion of fibers is mentioned. 
The enumeration can be considered as only approxi- 
mately correct ; yet it will serve as an aid in locating a 
lesion in the spinal cord, and perhaps will prove of 
most value where there is atrophy of muscles. As the 
skin over muscles is supplied by nerve-fibers from near- 
ly the same region as the muscles, the distribution of 
anaesthesia may serve roughly as a guide to diagnosis 
of the level of a lesion, though in such a case much less 
likely to be so nearly correct as when muscular symp- 
toms are the guide.* 

The first dorsal : The intrinsic muscles of the hand, 
viz., muscles of the thenar and hypothenar eminences 
and interossei. 

Eighth cervical : Long flexors, ulnar flexors of wrist, 
intrinsic muscles of the hand, extensors of wrist and 
phalanges, long head of triceps (pectoralis major ?). 

Seventh cervical : Teres major, latissimus dorsi, sub- 
scapularis, pectoralis major, flexors of wrist and fingers 
(median), triceps. 

Sixth cervical: Latissimus dorsi, pectoralis major, 
serratus magnus, pronators (flexor of wrist ?), triceps. 

Fifth cervical : Deltoid (clavicular portion), biceps, 
brachialis anticus, serratus magnus, supinator longus, 
extensors of wrist and fingers. 

Fourth cervical : Deltoid, rhomboid, supra- and in- 
fra-spinatus (teres minor), biceps, brachialis anticus, 
supinator longus, extensors of wrist and fingers, dia- 
phragm. 

In the lower extremity : 

Second sacral : Intrinsic muscles of the foot, strictly 
parallel to the first dorsal. 

First sacral: Muscles of the calf (plantar flexors), 
hamstrings, long flexor of big toe, intrinsic muscles of 
the foot. 

* See, also, M. Allen Starr, " Localization of the Functions of Spinal 
Cord," " Amer. Jour, of Neurolog. and Psychiat.," August and Novem- 
ber, 1884, p. 480. 



GENERAL SYMPTOMATOLOGY. 141 

Fifth lumbar : Flexors and extensors of toes, tibial 
muscles, sural muscles, peroneal muscles, outward ro- 
tators of thigh, hamstrings. 

Fourth lumbar : Extensors of thigh, extensor cruris, 
peroneus longus, adductors. 

Third lumbar : Ilio-psoas, sartorius, adductors, ex- 
tensor cruris. 

By keeping this general scheme in mind, an idea 
may be formed, nearly correct, of the level of the lesion, 
and a record may be made by which to judge whether 
it is extending or receding. 

A study or examination of the various reflexes will 
also aid in the formation of a diagnosis of locality. (See 
page 8.) 

There may not be paralysis, yet the motor conduct- 
ors may be seriously affected, so that, while all motions 
are possible, yet there is clearly a loss of strength, and 
the movements are very slow ; there is a retardation of 
the motor conduction ; Burckhardt thinks this points 
to disease of the white columns. 

Burckhardt has also studied the acceleration of mo- 
tor conduction. This is not very rare, but is more dif- 
ficult to recognize. Some cases of exaggerated reflex 
action may be due to this condition. Burckhardt refers 
this phenomenon to an affection of the gray substance. 

There may be no paralysis, but the motions may be 
irregular ; there is a loss of co-ordinating power, a con- 
dition known as ataxia, which Erb defines as " the dis- 
turbance of movement, produced by defective co-ordi- 
nation of movement." He considers that it is of a 
motor nature. While all motions may be performed 
with power, the patient can not execute any movement 
with precision ; the hand or foot is carried beyond or 
falls short of the point it is desired to touch, or it is 
carried to one side. In attempting to grasp an object, 
the strength put forth is out of proportion to the end 
to be gained. When extreme, this ataxia may be 
shown in all the motions ; if the defect is but slight, it 



142 DISEASES OF THE SPINAL CORD. 

may be necessary to ask the patient to close his eyes 
before the symptom can be clearly recognized. When 
the aid of sight is withdrawn, the patient may be un- 
able to touch a certain part of his face, as the chin or 
end of the nose, with his forefinger, or in walking may 
be unable to propel his feet properly. Yet not every 
defect in walking with closed eyes is due to ataxia ; 
weakness may cause a patient to totter and walk irregu- 
larly : vertigo may have a similar effect ; anesthesia of 
the soles of the feet or of the joints may cause a patient 
to stagger when the eyes are closed. 

Erb thus describes the ataxic gait: "It is charac- 
terized by irregular hurling movements ; the point of 
the foot is thrown forward and outward with force ; 
the heel is brought down with a stamp, the leg stiff at 
the knee. The patient's eyes are continually on the 
ground. The gait is tottering, staggering, or even reel- 
ing from side to side ; the movements are hasty, spas- 
modic, quite unequal ; in turning about, especially, 
there is great uncertainty, and danger of falling. In 
severe cases the patient falls after a few steps." This 
accurate description applies to rather advanced cases ; 
•there may be only a very slight degree of disturbance 
early in the disease. 

This ataxic condition, when dependent upon disease 
of the spinal cord, is the result of changes in the pos- 
terior columns, and more definitely the external radical 
columns. 

Involuntary muscular movements are among the 
prominent symptoms in certain affections of the spinal 
cord. These are of a reflex nature, or the result of 
direct irritation of the motor roots or motor regions of 
the cord. 

When the spinal cord is divided, or when destruc- 
tion by disease extends across the cord, so that commu- 
nication with the brain is cut off, reflex movements are 
exaggerated in all parts of the body below the seat of 
injury whose reflex nervous arc remains intact. The 



GENERAL SYMPTOMATOLOGY. 143 

reflex phenomena, as mapped out by Gowers, may as- 
sist, then, in locating the seat of the disease. (See 
above, p. 8.) 

When there is increased irritability of the gray sub- 
stance, the reflex motions in the regions supplied by 
nerves arising therefrom will be exaggerated. The 
same exaggeration is found in disease of the lateral 
pyramidal columns, as in secondary degenerations and 
sclerosis. 

The pupillary reactions are reflex : if the cervical 
region of the cord is destroyed, the pupils may be con- 
tracted ; if there is irritation, they will be dilated. The 
normal reactions will not be present. 

Reflex action may be much diminished or abolished 
when any portion of the reflex arc is diseased ; whether 
the sensory nerves or posterior nerve-roots, the gray 
substance, or the anterior motor regions, or motor 
roots, are diseased. Reflex action may be delayed 
under similar conditions under which sensory impres- 
sions are delayed. 

In cerebral disease the reflex actions may be abol- 
ished on the paralyzed side. 

Westphal first called attention to the fact that the- 
tendon reflex is lost at an early period in locomotor 
ataxia; this has been confirmed by others, and it is 
now generally accepted as true of that disease. It has 
been found absent when the columns of Goll were not 
affected, the external radical columns alone being dis- 
eased (Westphal). It is also lost when the spinal cord 
is entirely disorganized ; when the sensory or motor 
roots (or peripheral nerves) are destroyed ; when the 
anterior cornua are diseased, so as to cause muscular 
atrophy ; and in some other less definite conditions. 

The tendon reflex may be greatly exaggerated, and 
may be then readily shown in connection with tendons 
with which it is not usually noticed, as those of the 
triceps humeri, of the fingers, of the sterno-mastoid. 

This increase of the phenomenon is one of the symp- 



144 DISEASES OF TEE SPINAL CORD. 

toms attending sclerosis of the lateral columns ; it may 
be present also after injuries giving rise to spinal con- 
cussion (Edes), and in hysteria; it is sometimes seen 
during acute febrile diseases, as typhoid fever. As a 
symptom of disease of the spinal cord, it is most regu- 
larly associated with disease of the lateral columns, 
and we are not yet able to say that, when found in ap- 
parently exceptional relations, it is not dependent upon 
a change thus located. 

Ankle clonus is indicative of change in the lateral 
pyramidal columns. Growers says that a persistent an- 
kle clonus is always pathological ; in this he is proba- 
bly a little too emphatic, but its presence must be 
looked upon as strongly in favor of organic changes in 
the cord. 

The spinal cord, by a reflex mechanism, exerts a 
control over the bladder and rectum ; the will also 
regulates in some measure those viscera. When the 
contents of the bladder and rectum are sufficient to 
excite reflex action in their expulsory muscles, the 
sphincters relax, probably in consequence of an inhibi- 
tory action of the spinal centers, and an evacuation fol- 
lows. The will can restrain for a while this expulsive 
action, or can excite it before the reflex action would 
arise normally. 

If the spinal cord is destroyed above the lumbar 
enlargement, this voluntary control is lost, and then the 
contents of the viscera are expelled at intervals accord- 
ing as the reflex centers may be aroused to action by 
the irritation excited by the contents of the viscera. 
The patient then has his evacuations involuntarily, and 
without knowing that they occur. 

If the sensory tract alone is injured, the evacuations 
may occur without his knowledge, but he will have 
power to voluntarily evacuate the viscera. If the mo- 
tor tract is injured, the discharges will occur without 
the patient's control, but he will be conscious of the 
desire to evacuate the viscera, and will know when 



GENERAL SYMPTOMATOLOGY. 145 

the evacuation is accomplished. When the voluntary 
control is weakened, or partially lost, while the sen- 
sory tract is unimpaired, the patient is obliged to re- 
spond quickly to the calls of nature, or, the restraining 
influence of the will being slight, involuntary evacu- 
ation follows. 

As the centers of reflex action for th,e sphincters 
and the detrusor muscles are not identical, one may be 
affected independently of the other ; then there will be 
incontinence when the sphincters are paralyzed, reten- 
tion when the detrusors are paralyzed. In the latter 
case, the sphincter acting, the urine accumulates until 
it may, by mere mechanical pressure, overflow, and so 
there may seem to be incontinence when there is really 
retention. 

Spasm may affect the sphincters or the detrusors, 
and corresponding disturbances will follow. 

Perversion of the sexual functions occur in many 
cases of spinal disease, much more marked in men 
than in women. There may be great increase of sexual 
desire, with power to gratify it ; or the desire may be 
present without the power, or with greatly diminished 
power ; or there may be frequent nocturnal or diurnal 
emissions, or spermatorrhoea. All sexual appetite may 
be lost, and there may be complete impotency. Pria- 
pism, complete or partial, may continue for a long pe- 
riod. Among women a similar disturbance of sexual 
desire may occur, but these symptoms have been less 
fully studied than among men. We can not at present 
draw any positive conclusions by means of the above 
variations from the normal condition. 

Vaso-motor and nutritive changes are not uncommon 
in different forms of spinal-cord lesions. The simplest 
change is disturbance of capillary circulation ; the af- 
fected parts are more or less cyanotic, or they may be 
unnaturally pale ; in either case the temperature is be- 
low normal ; sometimes there is great increase of heat, 
with less apparent disturbance of circulation. In one 



146 DISEASES OF THE SPIRAL CORD. 

case there is irritation of the vaso-motor centers, in the 
other case paralysis. It is often noticeable that para- 
lyzed limbs are slightly cedematous, and sometimes the 
consequent swelling is very great. 

The skin may undergo changes similar to those found 
in neuritis ; there may be a scaly condition, due to ex- 
cessive multiplication of the epidermic cells ; the hair 
and nails may suffer in nutrition ; herpetic eruptions, 
pustules, and urticaria may be noticed. Bed-sores, 
chronic or acute, are the most troublesome trophic 
changes in some cases, and may gradually wear out the 
patient. The bones, especially their articular surfaces, 
undergo changes of structure and form, are worn away, 
or become brittle and easily break. 

The muscles undergo atrophy, their fibers becom- 
ing reduced to rows of fat drops or granules, and 
finally, these being absorbed, only the sheaths are left ; 
sometimes a deposit of fat between the muscular 
fibers obscures the wasting, and the affected limbs 
retain their usual proportions. The electrical reac- 
tion of degeneration will show whether this atrophy 
has occurred and enable one to form an opinion as 
to how far it has advanced. If only some fibers are 
degenerated, these reactions may be obscured and less 
readily obtained, the healthy fibers giving the normal 
reactions. This atrophy shows that there is lesion of 
the motor nerves or of the anterior cornu in the cord. 

The general nutrition of the body or limbs may be 
altered in disease of the spinal cord ; there may be great 
emaciation, or there may be an increased deposit of 
fat, subcutaneous, as well as in the deeper structures. 
When the nerve-cells of the anterior cornu are diseased 
in infancy, there is not only atrophy of the muscles, 
but, if the change is extensive, the paralyzed limb is 
retarded in its subsequent growth. 

The anterior part of the central gray substance is 
supposed to be the trophic center for the bones ; the 
posterior part for the skin, hair, and nails ; the ante- 



GENERAL SYMPTOMATOLOGY. 147 

rior cornua are the trophic centers for motor nerves and 
muscles. 

Sensation is entirely lost only when the whole of the 
posterior portion of the cord, including the gray sub- 
stance, is destroyed. If even a small portion of the 
gray substance remains, sensation' is not entirely lost. 
It is probable also that certain parts of the lateral col- 
umns convey sensation, though the mode of distribution 
of sensory fibers in these columns is not known. When 
both sides are destroyed, a narrow band of hyperes- 
thesia may be found above the level of the anaesthesia. 

If only one side of the cord is destroyed, there will 
be hyperesthesia below the seat of injury on the same 
side with it, and anaesthesia on the opposite side ; a 
narrow zone of diminished sensibility on both sides of 
the body will be found at the level of the injury, and 
above this for a short distance there may be hyperes- 
thesia on the same side with the injury. 

When sensation is not entirely destroyed, the differ- 
ent kinds of sensation, as touch, temperature, pressure, 
pain, etc., may be affected in unequal measure. 

When there is not destruction of the cord, there may 
be great hyperesthesia, and the increase of sensitive- 
ness may be so great that even a slight touch causes 
great suffering. This is found when there is inflamma- 
tion of the meninges, or when the posterior nerve-roots 
are irritated, as by compression, and rarely in inflamma- 
tion of the cord itself, though local hyperesthesia is 
common in locomotor ataxia, especially after an attack 
of lancinating pain. 

A sensation of a band tied around the body — a girdle 
sensation or pain — is frequently found in myelitis, and 
where there is compression of the cord. It is difficult 
to define its nature ; it is sometimes painful, sometimes 
simply a slight sense of constriction. It is seated at 
the level of distribution of the nerves arising from the 
upper limit of the disease ; sometimes the girdle seems 
to surround one or both legs instead of the body. 



148 DISEASES OF THE SPINAL CORD. 

When the posterior nerve-roots are exposed to irri- 
tation, as from pressure or inflammatory changes, pain 
of different kinds will be felt at the peripheral ends of 
those nerves ; if the nerves are suddenly compressed or 
bruised, a burning sensation, perhaps very painful, will 
be felt. The sensation referred to the periphery in 
disease of the spinal cord is much less likely to be 
pain ; it rather takes the form of tingling, numbness, 
formication, or that peculiar sensation known as being 
asleep. 

Backache is a very common complaint with patients ; 
it is more common in functional than in organic diseases. 
Tenderness on pressure over the vertebrae is rare in or- 
ganic affections ; it is common in connection with cer- 
tain functional disturbances. 



CHAPTEE X. 

SPINAL MENINGITIS. 

Joffroy, A., De la pachymeningite cervicale hypertrophique. 
Paris, 1873. — Spencer, W. H., Case of Idiopathic Inflammation 
of the Spinal Dura Mater. Lancet, June 14, 1879, p. 836. — Le- 
moine, G-., and Lannois, N., Perimeningite spinale aigue. Revue 
de Med., No. 6, 1882.— Tooth, Dorsal pachymeningitis. Brain, 
1884. 

There are two subdivisions of spinal meningitis — one 
affecting the dura mater, pachymeningitis; the other 
the pia mater, leptomeningitis. 

External pachymeningitis, inflammation of the ex- 
ternal surface of the dura mater, is caused by changes 
in the adjoining parts — caries, abscess, cancer, tumor, 
aneurisms penetrating from without, etc. The symp- 
toms will be so united with those caused by the pri- 
mary disease that it is unnecessary to describe them. 

PACHYMENINGITIS INTERNA. 

Internal pachymeningitis may occur independently 
of other lesions. Generally, not only the internal sur- 
face of the dura mater is affected, but its whole thick- 
ness may be the seat of inflammatory hypertrophy ; the 
pia mater may also be somewhat thickened and in- 
flamed secondarily ; it can usually be distinguished 
from the dura mater. 

Owing to the thickening of the membranes, the cord 
is compressed, and undergoes inflammatory changes ; 
sometimes cavities are formed. 

The nerve-roots suffer from compression and second- 
ary inflammation as they pass through the dura mater. 



150 DISEASES OF THE SPINAL CORD. 

The disease is confined almost exclusively to the 
cervical region. 

Symptoms. — During the first stage of the disease 
the prominent symptom is pain in the posterior part of 
the neck and the occipital region ; following the direc- 
tion of the peripheral nerves, it extends frequently in- 
to the arms ; it is aggravated by movements of the 
vertebra, sometimes is increased by firm pressure over 
the spine, and at times is extremely severe. Some- 
times before the pain ceases, more frequently after a 
period of comparative freedom from distress, para- 
lytic symptoms make their appearance, first weak- 
ness, which gradually increases to complete paralysis. 
With the paralysis there is atrophy of the muscles. 
The distribution of the atrophy is somewhat variable ; 
the muscles of the hand, the interossei, the lumbricales, 
and the muscles of the thenar and hypothenar eminen- 
ces are generally greatly atrophied ; in the forearm the 
flexors and extensors of the fingers, the flexors and 
pronators of the hand, are chiefly affected ; the muscles 
of the arm generally escape, while the deltoid and the 
supra- and infra-spinatus suffer. Owing to the atrophy 
of some muscles, and the fact that others are unaffected, 
the hand acquires an unnatural position : it is held in 
a position of extreme extension, with the fingers par- 
tially flexed, the thumb extended and adducted. In 
some cases this position may be overcome by passive 
motion ; in others it is noticed only when the forearm 
is in supination. 

If the disease affects the upper part of the cervical 
enlargement, the position of the hand is different. 
Ross thus describes the position : The arm is held close 
to the side, the forearm is extended on the arm and 
strongly pronated, the hand is flexed on the forearm, 
the fingers are in a line with or only slightly extended 
on the metacarpal bones, and the phalanges are ex- 
tended upon one another, while the thumb is flexed 
into the palm. The muscles supplied by the musculo- 



PACHYMENINGITIS INTERNA. 151 

spiral nerve are more affected than those supplied by 
the ulnar and median. 

The disease has rarely been observed in the lower 
part of the spine. 

The paralyzed muscles undergo atrophy, and the 
electrical reaction is changed ; there is found the reac- 
tion of degeneration, or entire loss of electrical reac- 
tion. 

Trophic changes in the skin, vesicular, bullous erup- 
tions, dry and scaly condition of the skin, and a glossy 
skin, are occasional phenomena; sometimes bed-sores 
form. The temperature is frequently lower than nor- 
mal. Slight convulsive shocks, and the phenomena 
attending lesion of the lateral columns, are sometimes 
met. 

Diagnosis. — The first stage, where there is only 
pain without impairment of motion, is difficult of diag- 
nosis. The pains may be referred to a rheumatic affec- 
tion, to spinal irritation or hysteria, or they may give 
rise to the suspicion that caries of the vertebrae is pres- 
ent. The pain due to pachymeningitis is said to be 
characterized by an increase during movement of the 
vertebrae, always deeply seated in the back part of the 
neck, on the median line ; frequency of the attacks of 
pain, and their short duration. 

When muscular atrophy sets in, the diagnosis from 
progressive muscular atrophy may be made from the 
history of the preceding attacks of pain, from the 
fact that the muscles are affected less regularly ; in 
muscular atrophy the hand will assume a more or less 
flexed position when in the stage of contracture, but in 
pachymeningitis the hand is extended and supinated, 
or the hand and arm take the position described by 
Ross. 

Treatment. — During the first stage the most press- 
ing indication is to relieve pain, for which sedatives 
and anodynes may be used ; hot iron applied to the 
neck and upper part of the dorsal region may give re- 



152 DISEASES OF THE SPINAL CORD. 

lief to the pain, and may also act favorably upon the 
progress of the disease. The galvanic current along 
the spine has been recommended, the positive pole 
above, the negative pole below, the cervical region. 
Paralysis and atrophy of the muscles can be treated 
locally by the faradic or galvanic current. 

Internally, iodide of potassium may be given. In 
judging of the value of treatment, it should be remem- 
bered that naturally the disease has periods of remis- 
sion. 

INFLAMMATION OF THE PIA MATER. 

Pathological Anatom y. — The term spinal menin- 
gitis is commonly used to designate inflammation of 
the pia mater, leptomeningitis. The pia mater is chief- 
ly affected; it is found congested, thickened, cedema- 
tous ; upon its surface and within its meshes there is 
more or less pus. The arachnoid is almost always im- 
plicated in the inflammatory process ; the dura mater 
is also sometimes involved. The amount of pus ex- 
uded varies greatly ; it may be so little as merely to give 
a yellowish tinge to the cedematous membrane, or the 
surface may be covered with a thick, creamy layer. 
The inflammation may extend over a very small sur- 
face, or may affect the whole cord. In about one third 
of the cases there is coincident cerebral meningitis. 

After the exudation has been absorbed, there may 
be left a thickening of the pia mater from the organi- 
zation of the inflammatory products ; the membranes 
may become adherent to each other, though this is rare. 

It can be easily understood that such serious dis- 
turbance of the pia mater, from which the spinal cord 
derives its blood-supply, must necessarily involve the 
spinal cord, and we almost always find some degree of 
myelitis associated with the meningitis. 

^Etiology. — The principal causes are exposure to 
cold and dampness, over-exertion of any kind, insola- 
tion, jars, concussions, falls upon the back, and inflam- 



INFLAMMATION OF THE PIA MATER. 153 

mation of neighboring parts. Occasionally, in tubercu- 
lar meningitis, tubercles are found in the spinal pia 
mater. 

Symptoms. — Sometimes a short prodromal period of 
general discomfort with fugitive pains precedes the at- 
tack of prominent symptoms, but generally the disease 
commences suddenly, with pain in the back and pain 
radiating into the limbs ; there is often a chill and the 
temperature rises; there may be headache and even 
vomiting, though this is rare, unless the disease is near 
the upper part of the spine or the cerebral membranes 
are also affected ; the surface of" the body becomes ex- 
tremely sensitive to the touch, the muscles of the ex- 
tremities are contracted, the body may be in position of 
opisthotonus, or there may be clonic spasms instead of 
tonic contraction of the limbs. 

The pain, which appears early in the back, is gener- 
ally very severe, is increased by the slightest motion, 
whether active or passive ; pressure upon the vertebrae 
may not increase it, but percussion almost always does ; 
extremes of temperature, either hot or cold, produce 
pain when applied over the region affected. The pain 
may radiate around the trunk in the form of a girdle, 
though this is perhaps less frequent than in myelitis ; 
it may also radiate with extreme severity into the limbs. 
The last phenomena are due to irritation of the nerve- 
roots. The cutaneous hyperesthesia is probably due 
to an irritation of the nerve-roots, and may be classified 
with other painful manifestations ; it is sometimes so 
extreme that even the weight of the bedclothes causes 
torture ; not only the limbs but the trunk may be thus 
affected, and the muscles and bones sometimes show an 
extreme degree of sensitiveness. 

The muscular stiffness and rigidity is probably at 
first due to an involuntary tension of the muscles in 
order to avoid motion because of the extreme pain pro- 
duced thereby ; later the contracture is probably due 
to direct irritation of the anterior nerve-roots. Some- 



154 DISEASES OF THE SPINAL CORD. 

times, especially at the beginning of the disease, clonic 
spasms add to the patient's suffering. 

There is generally constipation and retention of 
urine, sometimes with a frequent desire to pass it. 

Respiration is frequently interfered with, especially 
when the disease is seated in the cervical region, and 
death sometimes arises from this disturbance preceded 
by Cheyne-Stokes's respiration. 

When the contraction diminishes sufficiently, it is 
found that there is partial or total paralysis, and that 
sensation is more or less affected ; sometimes with pa- 
ralysis there remains contracture of the limbs, either in 
extension or flexion. The electrical reaction of the 
muscles may be lost, or undergo the modification of de- 
generation. 

Death frequently occurs after only a few days, or 
the patient may die at a much later period, apparently 
from exhaustion. Sometimes recovery is complete and 
perfect, but more frequently there remain partial pa- 
ralyses and atrophies. A chronic leptomeningitis last- 
ing for months or years is said sometimes to result from 
the acute disease. 

Diagnosis. — Jaccoud says : "The only two diseases 
of the spinal cord which have a febrile beginning are 
acute meningitis and acute myelitis ; now, as a rule, 
these two inflammations exist together, and the differ- 
ence in diagnosis is only a matter of refinement or a 
question of relative preponderance." The principal 
diagnostic symptoms of spinal meningitis are the pain 
in the back and limbs, the hyperesthesia, the muscu- 
lar spasm, and contracture. The opisthotonus might 
give rise to the suspicion that the disease is tetanus ; 
but in that there is much less fever, less pain, except 
during the spasm, and little or no cutaneous hyperes- 
thesia ; at the beginning there is trismus, the other 
spasms are more violent, and the reflex irritability is 
excessive. If there is recovery, it is, as a rule, more 
complete in tetanus than in spinal meningitis. 



INFLAMMATION OF THE PI A MATER. 155 

Prognosis. — The prognosis is said by Erb to be "in- 
fluenced for the worse by the following circumstances : 
A very youthful or very advanced age ; bad constitu- 
tion, ansemia, the previous occurrence of severe disease, 
etc. ; by the height to which the disease ascends in the 
spine toward the brain ; by early symptoms of paraly- 
sis, signs of general loss of strength, high fever, con- 
tinually rising temperature, and increasing frequency 
of pulse ; great difficulty in breathing, dysphagia, se- 
vere cerebral symptoms, etc." 

The disease is at best serious, and even after partial 
recovery relapses may occur. The paralysis and atro- 
phy that remain may disable the patient for the rest of 
his life. 

Treatment. — The sensitiveness of the skin may be 
such as to interfere with the use of cups, but, if possi- 
ble, dry or wet cups should be applied, or leeches may 
be used. ' Ice-bags should be kept constantly on the 
spine. After the first acute stage has passed, blisters 
or other counter-irritation may be applied over the spinal 
column. Most European authors recommend that mer- 
cury be used by inunction or internally. Ergot may be 
given in large doses frequently repeated. Iodide of 
potassium can be used after the earlier stages of the 
disease. The pain can be controlled by opiates, which 
should be given in large doses. 

It is scarcely necessary to mention that quietness, 
rest in bed, and the ordinary hygienic measures be ob- 
served. Decubitus on the side or prone is the best posi- 
tion in bed. 

The paralyses and contractures which remain after 
recovery may be treated by electricity, passive motion, 
friction, and baths. 



CHAPTER XL 

CHANGES IN BLOOD-SUPPLY. 

Mayer, Sigmund, Zur Lehre von der Anamie des Riieken- 
marks. Zeitschr. f. Heilk., iv, 1883, p. 26.— Gull, Paraplegia 
from Obstruction of the Abdominal Aorta. Guy's Hosp. Reports, 
1858, p. 311. 

SPINAL HYPEREMIA. 

Congestion, and its opposite, ansemia, of the spinal 
cord and its membranes have been too frequently men- 
tioned as causes of symptoms which evidently arise 
from more serious lesions. Clinically, and even patho- 
logically, it is difficult to draw the line of separation 
between congestion and inflammation. It is almost im- 
possible, also, to separate these lesions of the meninges 
from similar lesions of the cord itself ; indeed, the spi- 
nal cord is always more or less implicated when the pia 
mater is diseased. While it is probably true that many 
slight disturbances of health are ascribed to congestion 
when there is really inflammation, yet it is convenient 
to speak of congestion, and describe it as an independ- 
ent disease. 

^Etiology. — One of the most frequent causes is cold, 
acting upon the surface of the body when the patient 
is heated ; if dampness is combined with the cold, as 
when the patient's clothing is wet by a sudden shower, 
or when the patient, overheated, takes a cold bath, the 
influence of the cold is much increased. 

Suppression of the menses, or hemorrhoidal bleed- 
ing, or other habitual discharges, may act as causes of 
congestion. 



SPINAL HYPEREMIA. 157 

Excessive bodily exertion, especially walking and 
standing, violent sexual excitement, or excess of coitus, 
may have the same effect. 

Much of the backache, and some of the pain in the 
limbs found at the commencement of febrile diseases, 
are probably caused by spinal hyperemia. 

Symptoms. — As already mentioned, it is impossible 
to separate the symptoms caused by congestion of spi- 
nal meninges from those produced by congestion of the 
spinal cord itself. The following description may serve 
for both conditions : 

There is a heavy, dull pain in the small of the back, 
or higher, sometimes radiating into the legs with sub- 
jective sensations of numbness and pricking; some- 
times a girdle sensation is felt ; a weakness or partial 
paralysis of the legs is generally present ; rarely slight 
spasms or twitches of muscles. These symptoms ap- 
pear rather suddenly, and may be aggravated by lying 
on the back. Unless inflammatory changes are set up, 
they are not accompanied with febrile action, and are 
usually of short duration, not lasting more than a few 
days or, in rare cases, weeks. 

Diagnosis. — The diagnosis is to be made from the 
slightness of the symptoms and their short duration, 
and the absence of fever, rather than from any pecul- 
iarity of the symptoms themselves. 

Treatment, — Active treatment, such as bleeding 
and purgatives, have been recommended; but, instead of 
general bleeding, wet cups or leeches, on both sides of 
the spine, are better : dry cups may be used with ad- 
vantage in the same place. The actual cautery may be 
tried with reasonable expectation of benefit. Purga- 
tives may be of use, but, if pushed far, would be of dis- 
advantage, from the necessity of disturbing the patient 
too often. Ice-bags to the spine may be used to advan- 
tage. Internally, belladonna and ergot have been rec- 
ommended. 

It is better for the patient to be kept quiet, confine^ 



158 DISEASES OF THE SPINAL CORD. 

ment to the bed being preferred ; the causes liable to 
produce congestion should be avoided, and by some a 
position upon the back is forbidden. 

SPIXAL AN.EMIA. 

In animals, experiment has shown that the symp- 
toms of anaemia may vary according as it is suddenly 
produced, or is brought on gradually. If all the blood 
is shut off at once from the cord, convulsions occur ; if 
the cord is gradually deprived of blood, there is only 
loss of function, without convulsion. In man the sud- 
den stoppage never occurs, owing to the free anasto- 
moses. Sometimes, in aneurism of the aorta, anaemia 
of the cord is produced by occlusion of blood-vessels, 
and serious disturbance of function may result there- 
from. In general anaemia and chlorosis, in cardiac dis- 
ease, there may be a diminished supply of blood in the 
cord. 

The spinal symptoms are not sufficiently well de- 
fined to form a positive diagnosis from them alone. 
There is simply disturbed function, numbness, motor 
weakness, and tremor, without fever. There is a con- 
dition, usually called spinal irritation, which has been 
referred to anaemia of the spinal cord, but without suf- 
ficient reason. The diagnosis must be made chiefly 
from symptoms other than those due to the spinal dis- 
turbance. 

The treatment should be directed to the condition 
causing the anaemia ; the patient should be kept in bed 
on his back if the symptoms are at all serious ; hot- 
water bottles may be applied to the spine ; strychnia 
has been recommended. 



CHAPTER XII. 

SPINAL HAEMORRHAGE. 

Fox, E. L., Clinical Lecture on Spinal Haemorrhage. Med. 
Times and Gaz., Aug. 26, 1876, p. 219.— Goltdammer, E., Ein 
Beitrag zur Lelire von der Spinal- Apoplexie. Virch. Arch., lxvi, 
p. 1.— MacMunn, C. A., Notes on a Case of Spinal Apoplexy. 
Dublin Jour, of Med. Sci., March 1, 1880, p. 182. — Eichorst, H., 
Beitrag zur Lehre von der Apoplexie in der Buckenmarkssubstanz. 
Charite-Annalen, 1876, p. 192.— Hayem, C, Des hemorrhagies 
intrarachidiennes. Faris, 1872. 

MENINGEAL HEMORRHAGE. 

^Etiology. —Spinal meningeal haemorrhage, haema- 
torrhachis, is rather a rare affection. It occurs as the 
result of injuries and falls, or in consequence of over- 
taxing the strength ; secondarily as following aneurism, 
or during tetanus, epilepsy, or some acute diseases, 
yellow, typhoid, or pernicious fever. 

Pathological Anatomy. — The blood may be 
poured outside the dura mater ; it may fill the whole 
of the vertebral canal, but is more frequently spread 
over the posterior surface of the membrane ; again, it 
may be limited to a comparatively small extent. The 
cervical region is rather more frequently the seat of 
the haemorrhage. The condition of the blood, as found 
at the autopsy, depends upon the length of time that 
has elapsed between the attack and death. . 

Intra-meningeal haemorrhage, where the blood is 
effused between the dura mater and arachnoid, is less 
frequent than the preceding. Hayem found thirty- 
eight cases of extra meningeal haemorrhage, and only 
eleven of this variety. 



160 DISEASES OF THE SPIXAL COED. 

The haemorrhage under the arachnoid and into the 
pia mater is still more rare, Hayem finding only eight 
cases. 

Many times the blood found in these places is 
poured out only during the last hours of life, and has 
no effect upon the primary disease ; this is especially 
true where the haemorrhage is merely slight or punc- 
tiform. Where there is considerable blood, however, 
the spinal cord may be much compressed. 

Symptoms. — Many secondary haemorrhages give rise 
to no special symptoms, either because they are very 
slight, or because the primary disease masks the spe- 
cial symptoms which they would cause. 

The symptoms usually appear suddenly ; there is 
first severe pain, followed almost immediately by pa- 
ralysis. Occasionally the onset is more gradual. There 
are two classes of symptoms which must be recognized : 
those dne to pressure upon the cord, and changes in 
its structure ; those due to irritation of the membrane 
and nerve roots by the foreign body, the clot. 

The symptoms due to pressure upon the cord are 
primarily more or less complete paraplegia, affecting 
chiefly motion, but also giving rise to sensations of 
numbness ; after the commencement of the attack there 
may be pain in the back, or it may be absent. Reflex 
action may be exaggerated. The pressure may give 
rise to secondary changes in the cord, myelitis may fol- 
low ; the paralysis becomes more complete and perma- 
nent ; sensation may be more seriously implicated, con- 
tractions may appear, and, as the myelitis advances, 
may disappear ; the muscles may undergo atrophy. 

The symptoms due to irritation by blood-clot and 
pressure upon the nerve-roots are so united that it is 
scarcely worth while to separate them. These are pains 
radiating in the course of the nerves and others referred 
to the periphery, tingling and pricking sensations, more 
or less anaesthesia, with possibly tenderness to touch of 
the parts to which the nerves are distributed ; spas- 



MENINGEAL HEMORRHAGE. 161 

modic contractions, generally clonic, sometimes tonic ; 
subsequently there may be atrophy and diminished 
electric excitability. Disturbed vaso-motor action may 
be found either below or at the level of the haemor- 
rhage. 

The patient may entirely recover, but more fre- 
quently some paralysis and atrophy remain perma- 
nently, accompanied, perhaps, with contracture. The 
electrical reaction undergoes the usual change in atro- 
phied muscles. 

The membranes are not very prone to secondary in- 
flammation ; fever is rarely present ; the pulse may be 
weak and slow. 

The symptoms vary somewhat according to the local- 
ity of the haemorrhage. When the upper part of the 
cord is affected, the pain and contraction and reflex 
phenomena will be most marked in the upper extremi- 
ties ; oculo-pupillary symptoms will be observed, and 
there may be disturbance of respiration. When the 
seat of the haemorrhage is lower, the above symptoms 
will be absent, and the sensory and motor phenomena 
will be most marked in the back and legs ; the bladder 
and rectum may be affected, priapism may give annoy- 
ance, or erection may be less frequent, and sexual power 
diminished. 

Diagnosis. — The chief diagnostic symptoms are the 
suddenness of the attack, the signs of meningeal irrita- 
tion, the absence of cerebral symptoms, and the course 
of the disease ; sometimes also the cause will aid to a 
diagnosis. It may not always be easy to determine at 
first whether the vertebrae have been fractured or the 
cord itself injured by the accident which has given rise 
to the symptoms. Extreme motor paralysis, especially 
if reflex action is diminished, at the commencement of 
the disease, and serious implication of the sphincters, 
would lead to an inference that the cord itself is in- 
jured. 

A careful study of the symptoms would probably 



162 DISEASES OF TEE SPINAL CORD. 

be sufficient to prevent an error of diagnosis in regard 
to other affections of the cord and its membranes. 

Treatment. — The most important indication which 
should be strongly insisted upon is absolute rest. Erb 
says upon the side or face ; but the position is of less 
importance than the rest. Leeches or wet cups should 
be applied along the back. Strong purgation is recom- 
mended, but has the disadvantage that the patient must 
be disturbed too much. As in other cases of haemor- 
rhage, large doses of ergot may be given, if the case is 
one of those arising spontaneously. Pain may be re- 
lieved by opiates and anodynes. Later, iodide of potas- 
sium may be prescribed, and resulting paralyses can be 
treated by electricity, baths, passive motion, and mass- 
age. 

HAEMORRHAGE INTO THE SPINAL CORD.— HiEMATOMYELITIS. 

^Etiology. — Haemorrhage into the spinal cord is 
about four times more frequent in men than in women ; 
it occurs chiefly in early adult life — from twenty to 
thirty-five. It may arise in the course of inflammatory 
changes in the spinal cord as a secondary complication, 
or be caused by influences which favor the active flow 
of blood to the cord ; a fall, a strain in lifting heavy 
weights, or other excessive bodily exertion, may be a 
cause. These are more likely to prove efficient if the 
blood-vessels of the cord are diseased. 

Pathological Anatomy. — Of course, the primary 
change in the cord is its destruction and the disasso- 
ciation of its fibers by the effused blood. The clot 
undergoes changes similar to those which follow cere- 
bral haemorrhage. The cord undergoes inflammatory 
changes and softening. It may sometimes be difficult 
to determine whether the softening is caused by the 
haemorrhage or preceded it. Haemorrhage is most fre- 
quent in the gray substance. The muscles and nerves 
undergo secondary changes, such as are found when the 
spinal nerve-centers are diseased. 



EMMORREAGE INTO TEE SPINAL CORD. 163 

The meninges are almost always congested, but the 
inflammatory changes in them are not very marked. 

When the patient lives long enough, secondary de- 
generation, ascending and descending, will be found in 
the cord. 

Symptoms. — The symptoms due to haemorrhage into 
the spinal cord may be preceded by obscure symptoms 
of discomfort due to disturbances of circulation or nu- 
trition, which precede the rupture of the vessel, and 
perhaps depend upon the changes in the cord which 
give rise to the haemorrhage. These changes of nutri- 
tion may be such as are found in myelitis, yet the symp- 
toms caused thereby may not attract special attention, 
or may be the result of an acute disease,. as typhoid 
fever. 

When a blood-vessel ruptures, there may be intense 
pain in the back, continuing for a variable length of 
time, followed by paralysis of motion and sensation in 
the parts below. The occurrence of the haemorrhage is 
not always the cause of such tumultuous symptoms ; it 
may occur during sleep, or the symptoms may be de- 
veloped gradually during a period of several hours or, 
in rare instances, some days. In the latter case it is 
more probable that a myelitis has preceded the haemor- 
rhage. 

However it may arise, the chief symptoms are finally 
very similar. As the seat of the effusion is generally 
the central gray matter, sensation is more or less pro- 
foundly affected, and it may be entirely abolished ; mo- 
tion is restricted, and generally lost in the parts below 
the lesion. At the beginning there may be a certain 
amount of tetanic rigidity or spasmodic twitching, but 
this is of short duration, and the limbs are soon relaxed 
in paralysis. If the lesion is not so low as to implicate 
the lumbar nerves, the reflex irritability is increased, as 
in other cases where the lower part of the cord is sev- 
ered from communication with the brain, though im- 
mediately after the shock of the haemorrhage the reflex 



16± DISEASES OF THE SPINAL CORD. 

functions may be temporarily suspended. Conscious- 
ness and intelligence are not affected. 

At the very onset, if there has been no previous ele- 
vation of temperature due to other disease, there is no 
fever; soon inflammatory changes commence around 
the clot, and then the temperature may rise ; as yet few 
observations of these changes have been made. The 
temperature of the paralyzed limbs was noticed by 
Levier to be 0*2° to l - 9° C. higher than the arms, the 
thermometer being in the fold formed by bending the 
knee and in the axilla. 

As the secondary changes extend, the symptoms be- 
come more decided ; if there was only a partial loss of 
sensation, the anaesthesia becomes complete ; there is 
entire loss of motion instead of partial paralysis. The 
muscles which arise from the portion of the cord de- 
stroyed undergo atrophy and show the reaction of de- 
generation. As secondary degeneration extends below 
the seat of the lesion, the symptoms due to affection of 
the lateral columns appear. 

The bladder and rectum are paralyzed, the urine 
may be very quickly changed in character, may contain 
blood, may be intensely acid, or may soon become alka- 
line. Some of these changes in the urine are dependent 
upon disturbed innervation of the kidneys and not upon 
cystitis, which may later cause much trouble. 

Bed-sores sometimes form with amazing rapidity, 
and become enormous in size. 

The symptoms will vary somewhat, in different cases, 
according to the height at which the haemorrhage oc- 
curs and the amount of blood poured out. In view of 
the physiology of the cord, it will not be difficult to 
locate approximately the upper limit of the lesion and, 
somewhat roughly, its lower limit. 

Diagnosis. — Haemorrhage into the substance of the 
cord can be distinguished from meningeal haemorrhage 
by the more complete and suddenly occurring paraly- 
sis of both motion and sensation, by the absence of 



HEMORRHAGE INTO THE SPINAL CORD. 165 

signs of great irritation, and by the rapid appearance 
of bed-sores. The diagnosis may be easier in cases 
where there has been a preceding disease of the spinal 
cord. 

In rare cases the haemorrhage may be confined to 
one side of the spinal cord ; then the paralysis of mo- 
tion will be hemiplegic. The fact that there is no loss 
of consciousness, and that sensation is affected on the 
side opposite the motor disturbance, will prevent such 
a lesion from being mistaken for cerebral haemor- 
rhage. 

From myelitis arising spontaneously the diagnosis 
must be made by considering the causes, the mode of 
onset, and the progress of the symptoms ; a careful con- 
sideration of these points will probably prevent an error 
of diagnosis, unless the myelitis is developed with un- 
usual rapidity. MacMunn mentions intensely acid 
urine as peculiar to haematomyelia, distinguishing it 
from myelitis. 

From acute anterior poliomyelitis the diagnosis may 
be made by the fact that in this there is no disturbance 
of sensation, that the bladder and rectum are not para- 
lyzed, bed-sores do not form, and the fever, if any, is 
at the beginning, whereas in haematomyelia the fever 
appears later, unless the haemorrhage is secondary. In 
the former also there is a tendency for some muscles to 
regain their function ; in the latter the paralysis tends 
to increase. 

Peognosis. — If a large amount of blood is effused, 
the symptoms will be correspondingly severe, and the 
prognosis must be serious ; if only a small amount is 
effused, the symptoms will be proportionately light, 
and recovery, or partial recovery, may occur. If the 
haemorrhage is in the cervical region, death is more 
likely to follow. 

If the patient survives the first attack, he may die 
exhausted by cystitis or bed-sores. If he survives long 
enough, the paralyzed muscles may undergo atrophy, 



166 DISEASES OF THE SPINAL CORD. 

which may persist during the rest of life, accompanied 
possibly with contracture. 

Treatment. — It is quite unlikely that any measures 
directed to stopping the bleeding can be applied in sea- 
son to be of any advantage. To prevent further dam- 
age by a renewal of the haemorrhage or by secondary 
myelitis, the patient should be kept quiet, and cold ap- 
plied to the back continuously. Local blood-letting 
may be resorted to, ergot may be given internally, pain 
should be relieved, the bowels and bladder should be 
sedulously cared for, the danger of bed-sores should be 
kept in mind, and subsequent paralyses and atrophies 
should be combated by the usual means. 



CHAPTER XIII. 

COMPRESSION OF THE SPINAL COED. 

Kadner, Zur Casuistik der Ruckenmarkscompression. Arch, 
der Heilkunde, 1876, p. 481. — Kahler, O., Ueher die Veranderun- 
gen welche sich im Riickenmarke in Folge einer geringgradi- 
gen Compression entwickeln. Zeitschr. f. Heilk., iii, 1882, p. 
187.— Humphrey Laurence, Slow Compression of the Spinal 
Cord. Lancet, Jan. 5, 1884, p. 14.— Sayre, Lewis A., Spinal 
Disease and Curvature. London, 1877. — Marsh, H., On the Di- 
agnosis of Caries of the Spine in the Stage preceding Angular 
Curvature. Brit. Med. Jour., June 11, 1881, p. 913. — Russel, 
William, The Early Diagnosis of Spinal Caries. Brit. Med. Jour., 
Nov. 12, 1881, p. 771. 

SLOW COMPRESSION. 

Sudden compression, in so far as it is not surgical, 
has been mentioned in connection with spinal menin- 
geal haemorrhage. 

^Etiology. — Slow compression is caused by caries 
of the vertebrae, by thickening of the membranes 
(pachymeningitis), by cancer of the vertebrae, or by 
tumors within the vertebral canal. 

Pathological Anatomy. — The changes found in 
the cord are the same as those found in myelitis ; 
sometimes the destruction is complete, the cord being 
softened ; sometimes it is pressed out of shape, and has 
undergone chronic interstitial changes, which give it 
a consistency firmer than natural. Secondary degen- 
erations are found above the point of compression in 
the posterior columns, sometimes in the cerebellar tracts, 
below in the anterior and lateral pyramidal columns. 

The membranes are more or less inflamed, thickened, 



168 DISEASES OF TEE SPINAL CORD. 

and covered perhaps with pus ; especially in caries the 
dura mater may be pressed inward by collections of 
pus so as to press upon the cord. It is rare to find the 
vertebral canal so narrowed by displacement of the ver- 
tebrae that the bones press upon the cord. If there is 
no pus formed behind the dura mater, and if myelitis 
is not set up, the bones may soften and fall together, 
so as to form a very marked curvature, with almost no 
symptoms referable to the cord. 

If the membranes are inflamed and thickened, the 
nerves, as they pass out of the vertebral canal, sur- 
rounded by the diseased membrane, are also inflamed. 

Symptoms. — The symptoms will vary according to 
the level of the disease causing the compression ; but 
there are symptoms common to all localities. 

The earlier symptoms are dependent upon irritation 
of the nerves or the membranes ; subsequent symp- 
toms depend also upon disease of the cord. 

Pain generally first attracts attention. The pains 
due to irritation of the nerve-roots are of a shooting, 
darting character, referred to the peripheral distribu- 
tion of the affected nerves. If the upper cervical 
nerves are thus irritated, the pain may be felt over the 
back of the head, the side of the face near the angle of 
the jaw, or over the neck and shoulders. When the 
cervical or lumbar nerves are affected, the pain will be 
felt in the limbs. If the dorsal nerves, the pain will be 
felt in the chest or upper part of the abdomen, usually 
near the median line, sometimes a little on one side. 
It may simulate angina pectoris, or the stomach-ache, 
or colic, according to location. Instead of pain, there 
may be only a sense of discomfort or irritation, as 
itching. Motions which change the relation of the ver- 
tebrae to one another, as bending, or twisting the trunk, 
may increase the pain very much, this is especially so 
when the vertebrae are diseased. Jars, as in riding, or 
percussion on the shoulders, will increase the pain 
when the vertebrae are diseased. 



SLOW COMPRESSION. 169 

Hyperesthesia may be noticed during or immedi- 
ately after the attacks of pain. This hyperesthesia 
may also be noticed between and independently of the 
attacks. 

Common sensation may be very much diminished. 

These disturbances of sensation depend upon le- 
sion of the nerves, and belong to the earlier symptoms. 
Later, the backache may be more marked ; there appear 
pains depending upon lesion of the cord, less lancinat- 
ing in character, which resemble those found in myeli- 
tis from other causes. These pains are found in the 
parts supplied with nerves arising from the cord below 
the seat of compression ; they consist in sensations of 
numbness, pricking or tingling, a sleepy sensation, as 
though the parts were asleep, or an aching. Ordinary 
sensation may be diminished or retarded. Finally, 
there may be complete anaesthesia below the lesion. 

In the beginning, even before there is any pain, 
there may be motor symptoms, which are frequently- 
overlooked. There is first a sense of fatigue ; the pa- 
tient dislikes to exert himself, and, if a child, will ex- 
change his active plays for more quiet sedentary ones. 

When carefully observed, he will be noticed to have 
a peculiar stiff gait, and, in stooping, the back will be 
kept rigid and the knees will be bent instead. This 
is most marked in caries and other diseases of the ver- 
tebrae. If the cervical vertebrae are affected, the pa- 
tient will steady his head with his hands when lying 
down or rising. Passive motion will be resisted, and, 
if the head or body is moved forcibly, pain will be ex- 
cited. 

The muscular weakness gradually increases until 
the patient is no longer able to support himself on his 
legs. Finally there is entire motor paralysis. 

When the disease is above the lumbar enlargement, 
the cutaneous reflexes are often exaggerated, so that 
severe contractions may follow even slight irritations. 
Tendon reflex may be increased, and ankle clonus may 



170 DISEASES OF THE SPINAL CORD. 

be excited. When paralysis is complete, there is usu- 
ally contraction of the legs upon the thighs, and of the 
thighs upon the pelvis. This may be so strong that 
it can not be overcome by any reasonable amount of 
force. 

General epileptiform convulsions occasionally occur 
even when the disease is situated in the lower part of 
the cord. 

The muscles may undergo atrophy. There may be 
herpes zoster; bed-sores may form. Disease of the 
joints, spinal arthritis, has been seen in vertebral caries. 

In caries and cancer of the vertebrae, these symp- 
toms may be independent of any deformity ; neither is 
there tenderness on pressure over the spinous processes 
until after the earlier stages. 

When the cervical or upper dorsal part of the cord 
is affected, the pupil may be widely dilated or con- 
tracted ; generally the latter. The face and eyes may 
be more or less congested from paralysis of the vaso- 
motor nerves. 

The temperature of the whole body may be influ- 
enced by the disease in the cervical region. The heart's 
action may be slow ; respiration may be disturbed. 

Diagnosis. — It is important to form a correct diag- 
nosis early in vertebral caries, especially as the longer 
the delay the more likelihood there is of deformity. 

The earliest symptoms have already been mentioned, 
and whenever they are met a careful examination should 
be made of all the circumstances attending their origin, 
cause, and development. The physician must disabuse 
himself of the idea that in caries of the vertebrae there 
is necessarily deformity or tenderness to pressure over 
the spine ; there may not be tenderness even to direct 
percussion in the early stage, but percussion on the 
shoulders may give rise to pain in the diseased parts. 

Acute spinal meningitis is attended with pain in 
the back and limbs, but it commences suddenly with 
fever, and is evidently a severe affection. 



SLOW COMPRESSION. 171 

The pain attending spinal irritation may lead to a 
suspicion of compression of the cord, and it may not 
always be easy at once to say there is no disease of the 
bones. The attending symptoms will generally clear 
up the diagnosis. There is less of the peculiar stiffness 
of gait and carriage, the pain is not felt so acutely at 
the peripheral end of the nerves, the pain is not in- 
creased by percussion on the head or shoulders to the 
same degree, and in spinal irritation there is much 
greater tenderness on pressure over the spinous pro- 
cesses than is ever found in compression at so early a 
date. The age of the patient, the history of the origin 
of the affection, and the past history of the patient, 
may aid in diagnosis, as will also the hysterical physi- 
ognomy which is often to be noticed in the less serious 
affection. 

The diagnosis between the different causes of com- 
pression of the spinal cord must often be made from 
symptoms other than those belonging to the spinal dis- 
ease itself. Aneurisms of the aorta may erode the ver- 
tebrae and press on the cord ; there is usually very lit- 
tle difficulty in recognizing the nature of this affection. 

Cancer of the vertebrae may give rise to very similar 
symptoms with caries. When the pain, shooting along 
the course of the nerves, is extremely severe, without 
intermission, apparently independent of movement, the 
probability is that it is caused by cancer ; yet, early in 
the disease, the pain may be much less severe, or may 
be scarcely noticeable. The spinal cord itself is less 
frequently implicated in cancer, and there is not the 
formation of pus which is seen when the bodies of the 
vertebrae are carious. 

The age of the patient may aid in diagnosis, caries 
being most frequent in early childhood, an age when 
cancer is very rare. 

The presence of cancer elsewhere, and the cancerous 
cachexia, would aid materially in diagnosis. 

A tumor within the vertebral canal may give rise to 



172 DISEASES OF THE SPINAL CORD. 

symptoms closely resembling those of caries. The 
pain, central and peripheral, may be the same ; the 
paralysis may be similar. There is less marked stiff- 
ness in gait, less difficulty in bending the spine ; per- 
cussion of the shoulders is less painful. The age of 
the patient, and his previous history, will aid the diag- 
nosis. If a slight deformity is discovered, tumor would 
be excluded. 

Prognosis. —The prognosis of caries is not very un- 
favorable. If there is deformity, it can not be reme- 
died, but even extreme paralysis may disappear, and 
the patient recover. If muscles have undergone atro- 
phy, they may be partially restored. The nearer the 
disease is to the medulla, the more serious is the con- 
dition, and the greater danger of sudden death. 

The prognosis in cancer of the vertebrae and tumors, 
or aneurisms penetrating the spinal canal, is necessarily 
unfavorable. 

Treatment. — Of internal remedies, those which 
will restore the general health when the constitution is 
broken down are of most value. 

In caries the only hope of recovery is to be found in 
ankylosis of the diseased vertebrae. As the inflam- 
mation around the diseased bones is increased by their 
pressure one upon the other, and by the friction of dis- 
eased surfaces against one another, it is necessary, in 
order to diminish that influence as much as possible, to 
keep the diseased j)arts quiet and relieve the bodies of 
the vertebrae of pressure. The means of accomplish- 
ing this need not be mentioned here ; it belongs rather 
to surgery. The treatment of cold abscesses also be- 
longs to surgery. 

To relieve the paralysis in caries of the spine, the act- 
ual cautery, applied by the side of the spine, has been 
used with excellent results. This can not well be ap- 
plied while the patient is wearing a jacket, except as 
that is removed for a day or two, and this is rarely 
advisable. 



SPINAL TUMORS. 173 

Electricity, faradic or galvanic, to stimulate para- 
lyzed muscles, should be used. 

The nutrition of the patient should be maintained 
as well as possible ; cod-liver oil and cream are espe- 
cially indicated in strumous subjects. The patient 
should be placed in the best hygienic conditions possi- 
ble. 

SPINAL TUMORS. 

The more common varieties of tumors found in the 
vertebral canal are cancer, generally arising from the 
vertebrae ; sarcoma and fibro-sarcoma, and osteoma ; 
parasites, echinococcus, or cysticercus, are more fre- 
quently connected with the membranes ; tubercular 
and syphilitic tumors may be either connected with 
the membranes or be seated in the substance of the 
cord itself ; gliomata are found in the substance of the 
cord. 

From pressure or from secondary inflammatory 
changes the spinal cord undergoes a degenerative pro- 
cess usually leading to softening ; sometimes, how- 
ever, there is simply atrophy of the nerve-elements, 
and the cord may acquire a somewhat firmer con- 
sistency than normal. When the tumor is in the sub- 
stance of the cord, its center may undergo degen- 
eration, and, by a process of softening, a cavity be 
formed. Many of the cavities found in the spinal 
cord originate in this way ; gliomata are most liable 
to this change. 

JEtiology. — Except in cases of tubercle, syphilis, 
and cancer, we know very little about the causes of 
spinal tumors, and even in regard to these varieties we 
can only say that the germs are conveyed by lymphat- 
ics or blood-vessels to their new seat of growth, or that 
a corresponding diathesis causes their growth. Some- 
times it would seem that an injury, as a fall or a blow 
upon the back, has served as a starting-point for the 
growth of tumors. 



X74 DISEASES OF TEE SPINAL COED. 

EXTRA-MEDULLARY (MENINGEAL) TUMORS. 

Symptoms. — The symptoms are almost the same as 
those found in connection with caries of the vertebrae. 
There are the symptoms due to irritation of nerve-roots 
and those depending upon compression of the cord. 
The symptoms may be unilateral or bilateral, according 
to the locality of the tumor. The growth of the tumor 
is usually very slow, and the development of the symp- 
toms is correspondingly slow, the slighter early symp- 
toms sometimes continuing for years before a definite 
diagnosis can be made. Pain at the seat of the tumor, 
of a dull, pressing nature, may be increased by motions 
of the body, but is felt at other times also. Percus- 
sion over the spinous processes may increase the pain 
or give it for a moment a more lancinating character. 
The nerves arising from the level of the tumor may 
be implicated ; then the pain will be felt at the periph- 
ery, as in caries. Atrophy of the muscles to which 
these nerves are distributed with the reaction of de- 
generation will indicate the serious change which the 
tumor may cause in the nerve-roots. Other trophic 
lesions, as herpes and bed-sores, may make their ap- 
pearance. 

Paralysis finally sets in with increased reflex irrita- 
bility, spasms, or contractures. A careful study of the 
nerves affected, as shown by the distribution of the 
paralysis or the anaesthesia, will indicate the level of 
the disease, and show also whether the cord is affected, 
or only the nerves of the chorda equina. 

Diagnosis. — No symptoms or combination of symp- 
toms are * sufficient for forming a positive diagnosis; 
it is only by a careful examination of all the circum- 
stances that other affections can be excluded and the 
probability of a tumor be recognized. Caries and can- 
cer of the vertebrae most closely resemble tumor in 
their symptoms. 



INTRA-MEDULLART SPINAL TUMORS. 175 

INTRA-MEDULLARY SPINAL TUMORS. 

The tumors which have been found in the substance 
of the cord are gliomatous, tubercular, syphilitic, or 
sarcomatous. They are very rare. Their growth is 
often slow, but they give rise to symptoms sooner than 
the extra-medullary growth. There is no necessity for 
describing these growths, as they are like others found 
elsewhere. 

Symptoms. — The symptoms are very much like those 
belonging to acute or chronic myelitis, including dis- 
turbance of sensation and motion, atrophy of muscles, 
and local trophic changes. Sometimes the symptoms 
much more closely resemble those due to meningeal 
tumor, pain, both local and peripheral, and increased 
reflex irritability, being prominent. The symptoms 
must vary with the seat, rate of growth, and conse- 
quent size of the tumor. There are no symptoms diag- 
nostic of spinal tumors by which one can be guided to 
a certain conclusion. 

Prognosis. — The prognosis is necessarily unfavor- 
able. A syphilitic gummata may theoretically be ab- 
sorbed, but it would then be impossible to satisfy a 
skeptic that the diagnosis was correct. 

Treatment. — Except the use of iodide of potassium 
or some equivalent preparation, there is nothing to be 
done further than to care for the patient's comfort and 
look after any complications which may arise. 



CHAPTER XIV. 

SYRINGOMYELIA. — FORMATION OF CAVITIES. — HYDRO- 
MYELUS. 

Schuppel, 0., Ueber Hydromyelus. Archiv der Heilk., vi, 
1865, p. 289. — Westphal, Ueber einen Fall von Hoblen- und Ge- 
schwulstbildung im Riickenmarke mit Erkrankung des verlanger- 
ten Marks und einzelner Hirnnerven. Arch. f. Psych, und Ner- 
venkr., v, 1875, p. 90.— Simon. Ibid., p. 108.— Schultze, F. Ibid., 
viii, 1878, p. 367.— Eickholt, August. Ibid., x, 1880, p. 695.— 
Westphal, C, A Contribution to tbe Study of Syringomyelia 
(Hydromyelia). Brain, July, 1883, p. 115. 

Occasionally cavities are found in the spinal cord, 
which are clearly the result of an abnormal develop- 
ment of the central canal ; this condition may be con- 
genital. The canal may be dilated through only a short 
tract, or through nearly its whole length. Sometimes 
the canal is double, or diverticula may be found which 
branch from the canal and can be followed for a few 
millimetres, running near the central canal. As an- 
other variety of malformation, cases are seen where the 
central canal has not been closed. The central canal 
may be secondarily dilated, when by pressure it is 
closed above or below the dilated portion, or it may be 
found dilated in connection with certain diseases, as 
cerebro-spinal meningitis, or occasionally in cases of 
chronic myelitis. 

In all these instances in which the central canal is 
enlarged, the walls of the cavity will be lined with epi- 
thelium, and it will be situated the same as the normal 
canal with reference to other parts of the cord. 



FORMATION OF CAVITIES. 177 

In a large number of cases, however, the cavity is 
pathological and is independent of the central canal, 
which may be seen just in front or to one side of the 
abnormal cavity ; the central canal is usually distorted, 
and it may be so flattened as to be scarcely recogniz- 
able, only a narrow line of epithelial cells showing its 
location. An abnormal cavity, according to Simon, 
may be lined with cylindrical epithelium, as when one 
is formed in a glioma. He thinks position is most im- 
portant for diagnosis. 

The cavity is most frequently found in the posterior 
part of the cord, it may be formed at the expense of 
the gray commissure or the posterior cornua, may take 
part of the space occupied by the posterior columns, 
or it may be in the anterior cornua. The gray sub- 
stance is much the more frequently affected. The cav- 
ity may be single or double, may be a few millimetres 
in length or may extend the whole length of the cord, 
and may be very small or as large as the finger. 

^Etiology. — The cause of the formation of a cavity 
is not the same in every case. A haemorrhage into the 
cord may leave a cavity after the clot has been absorbed ; 
the plugging of blood-vessels, much more rare, may be 
the cause. Several cases have been reported in which 
it has seemed that a glioma formed in the central gray 
substance, and that the center of this has softened and 
been absorbed. Hallopeau has suggested that an in- 
flammation about the central canal may give rise to an 
enlargement of that canal, or a central myelitis may 
lead to the formation of a canal outside the central canal. 

Eichorst and Naunyn found that, after crushing 
the cord in young animals, a cavity was formed above 
the point crushed. They referred this to the dilatation 
of a lymph-canal which they suppose runs at the bot- 
tom of the posterior fissure. Westphal accepts this as 
a possible explanation of the formation of some cavi- 
ties. 

There are no special symptoms caused by cavities, 
12 



178 DISEASES OF THE SPINAL COED. 

so far as is known. Those symptoms which have been 
found in cases of syringomyelia were such as were due 
to the disease which gave rise to the cavity. 

There is nothing to be said as to treatment other 
than what belongs to the primary disease, if any, which 
causes the formation of the cavity. 



CHAPTER XV. 

MYELITIS. 

Frommann, C, Untersuchungen iiber die normale und patholo- 
gische Anatomie des Kuckenmarks. Jena, 1864, 1867. — Dujar- 
din-Beaumetz, G., De la my elite aigue. Paris, 1872. — Anderson, 
M'C, On a Case of Myelitis. Edin. Med. Jour., Aug., 1881, p. 
97. — Hallopeau, H., Etude sur les my elite chroniques diffuses. 
Arch. gen. de med., Sept., 1871. — Zunker, Beitrage zur Myelitis 
Chronica. Charite Annalen, v, 1880, p. 260. 

Myelitis is an inflammation of the spinal cord, and 
may be acnte or chronic ; the gray or the white sub- 
stance may be affected, the nervous tissues, cells, and 
fibers may be chiefly and primarily affected, or the 
principal change may be found in the interstitial tis- 
sue, the nervous structures suffering secondarily. 

ACUTE MYELITIS. 

./Etiology. — Acute myelitis is most frequently 
caused by exposure to wet and cold ; these two influ- 
ences are most likely to give rise to inflammation of the 
spinal cord when the legs, more especially the thighs, 
and the back are thus exposed for a considerable length 
of time, as by sleeping upon the damp ground in cool 
weather, or riding in a carriage or on horse-back in a 
storm, with insufficient protection. The influence of 
the above causes is very much increased if there has 
been severe or prolonged bodily exertion at the time 
of the exposure or just preceding it. Excessive bodily 
exertions may alone be the cause of the disease. 

Many acute febrile diseases are occasionally accom- 



180 DISEASES OF THE SPIRAL CORD. 

panied by a myelitis ; this will be referred to again 
(post-febrile paralysis). 

Lead-poisoning is not unfrequently the cause of 
symptoms closely resembling those of myelitis ; in- 
deed, it is probable that in such cases there is inflam- 
mation of the spinal cord, but generally of a chronic 
form. 

Excess in venery, and syphilis, may give rise to 
myelitis ; so may injuries to the back, from falls, blows, 
etc. 

Severe emotions, as fright and anger, may occasion- 
ally give rise to inflammation of the spinal cord. 

Pathological Anatomy. — The spinal cord affected 
with acute myelitis is generally softened, but occasion- 
ally its consistency is increased. The softening may 
be only slight, or the cord may be quite liquid. The 
color is either reddish, if there is an admixture of blood 
with the debris of the cord, or yellow, if fatty degen- 
eration has occurred to any extent, or white. The soft- 
ening may occupy a continuous stretch of the cord, 
or it may be scattered about in isolated spots ; the gray 
substance is rather more easily affected than the white. 

The dorsal region is more frequently the seat of 
softening than either the cervical or lumbar. When 
the cervical region is affected, it is said that the dis- 
seminated variety is the more common. 

Above the portion directly affected there is found 
secondary ascending degeneration of the posterior col- 
umns and cerebellar tracts ; below, secondary descend- 
ing degeneration of the pyramidal tracts. This second- 
ary degeneration can be best seen from the change of 
color after hardening in bichromate of potassa or chro- 
mic acid. 

With the microscope, the minute changes of struct- 
ure may be studied better upon hardened specimens. 
Either the nervous structures are chiefly affected, or the 
interstitial tissue is first altered. The nerve-fibers are 
first swollen, the myeline becomes granular, and the 



ACUTE MYELITIS. 181 

axis cylinder is either broken up and disappears or is 
enlarged, even to ten times its normal diameter ; these 
enlarged axis-cylinders may be filled with cavities— 
vacuoles ; the enlargement is varicose or affects only a 
short length of the axis ; it may be spherical or fusi- 
form. These enlarged axes soon break up and disap- 
pear in the general debris of the softened tissue. When 
the cord acquires increased consistency, this hypertro- 
phy of the nerve-fibers is either entirely wanting or is 
very slight. 

The nerve-cells are also swollen, acquire a globular 
appearance, their outline may be less distinct than nor- 
mal, and the nucleus may be pushed to one side, even 
so as to project beyond the general outline of the cell ; 
they may be filled with vacuoles, or they may have a 
shining, glassy appearance — vitreous. There may be a 
large deposit of pigment in the cells. They finally 
become granular, break up, and disappear. 

Changes in the neuroglia may be the starting-point 
in myelitis ; then those in the nervous structures are 
secondary, and there is less likely to be hypertrophy 
of the nerve-fibers and cells. The nuclei of the neurog- 
lia multiply, the fibers swell up and are thicker, and 
they become brittle and undergo fatty degeneration. 
Granular corpuscles form at the expense of the nuclei 
and connective tissue. As the nutrition of the nervous 
elements is interfered with, they also degenerate, and 
the cord is soon reduced to a soft, semi-liquid consist- 
ency. When the cord acquires an increased consist- 
ency, the fibers and cells of the neuroglia are multiplied 
somewhat as in sclerosis, though to a less degree ; the 
nerve-fibers in these cases are destroyed, and their place 
is filled with granular debris or a liquid which becomes 
granular on hardening. 

The walls of the blood-vessels are rarely if ever 
thickened in acute myelitis ; they are more likely to 
lose consistency and rupture easily, giving rise to haem- 
orrhages which aid in the process of disintegration. 



182 DISEASES OF TEE SPIJSTAL CORD. 

The walls of the vessels are often covered with granular 
corpuscles. 

Symptoms. — Acute myelitis may begin with a chill 
and fever before any distinctive spinal or nervous symp- 
toms appear. The temperature only rarely reaches 
104° ; the pulse may be as high as 150 ; with the py- 
rexia are the usual constitutional symptoms — anorexia, 
headache, and general malaise. 

Very frequently the commencement of the disease 
is more gradual ; a sense of weariness, heaviness, with 
backache and undefined sensations in the limbs, precede 
the initial fever. 

Soon after the chill and fever, sometimes without 
any distinct pyrexia, a numbness or a pricking and 
tingling is noticed, usually in the toes and feet. These 
abnormal sensations increase in severity and gradually 
extend up the leg. 

"With these symptoms, or soon after their advent, 
rarely as the initial symptom, the patient is aware of a 
loss of strength in his legs ; he is soon wearied in walk- 
ing ; in a very short time this increases, so that he is 
unable to walk, and must keep his bed. In many in- 
stances there is tremor or cramps at the beginning of 
the attack, but no marked convulsions nor spasms. 

The disturbance of motion and sensation extends 
upward, affecting both limbs with increasing and nearly 
equal severity, until there may be entire paralysis of 
motion and complete loss of sensation in the legs. 

The different reflexes, cutaneous and deep-seated, 
are first diminished, then lost, unless the myelitis is 
limited to a comparatively short segment of the cord 
above the lumbar region. The reflex actions which 
control the bladder and rectum are lost ; there is, at 
first, usually retention of urine ; later the urine drib- 
bles away from over-distention of the bladder and pa- 
ralysis of the sphincter. There is constipation rather 
than involuntary action of the bowels. 

A sense of constriction, girdle sensation, is noticed 



ACUTE MYELITIS. 183 

around the thighs — later around the waist. This may- 
be very annoying to the patient. 

As the inflammation extends upward in the cord, 
the trunk is affected, the costal respiratory muscles 
cease to act, the respiration becomes diaphragmatic, 
there is inability to expel the mucus which may accu- 
mulate in the bronchial tubes ; the breathing therefore 
becomes noisy, the upper extremities are also affected, 
the patient finally ceases to breathe, and dies of apncea. 

When the inflammation extends downward rather 
than upward, its progress can be recognized, though 
less certainly, by observing the loss of reflexes in a de- 
scending order, or the gradual extinction of electrical 
reactions. For this, careful comparative examinations 
are necessary, such as it is not always desirable to 
make. 

Pain is not a prominent symptom in acute myelitis ; 
it is not present unless the membranes are also impli- 
cated. The tingling numbness may be so severe as to 
give the patient much discomfort, and there may be 
aching and a sense of unrest in the limbs ; but it is not 
rare to have the disease run its course without even this 
amount of discomfort. Backache is said by some to be 
one of the symptoms of acute myelitis ; if this is promi- 
nent, there is probably an accompanying meningitis. 
There is no tenderness over the spinous processes, and 
spontaneous spasms or evidences of reflex irritability 
are wanting. Pain or tenderness may be shown by 
passing a sponge wet with hot water, or a lump of ice, 
over the back ; a severe burning sensation will be felt 
at the seat of the lesion. Electricity will sometimes act 
in the same way. Hyperesthesia of the skin is not 
found in myelitis, excepting occasionally a narrow zone 
at the upper limit of the region affected with anaesthe- 
sia. Symptoms of motor and sensory irritation, how- 
ever, are often seen in cases of myelitis, because very 
frequently the membranes are implicated. 

A tonic contraction of the legs, a rigidity in exten- 



184 DISEASES OF THE SPINAL CORD. 

sion, is a symptom which belongs to the later stages, 
when the disease is above the lumbar enlargement; 
there is then difficulty in abducting the legs, and pass- 
ing a catheter may become difficult from the exaggera- 
tion of this contraction caused thereby. 

The urine may become alkaline early in the disease, 
as Erb thinks, not improbably from direct nervous dis- 
turbance of the secretory functions. There is always 
danger, also, of this change in the urine from retention, 
the bladder being only imperfectly emptied. Cystitis 
is one of the complications to be watched for. When 
the lumbar enlargement is not affected, the urine may 
be passed involuntarily, and, if sensation is much dis- 
turbed, without the patient's knowledge. Bed-sores 
sometimes form with great rapidity, enormous masses 
of tissue sloughing away and giving rise to possible 
purulent infection. Even if such acute disturbance of 
nutrition does not occur, it is very common to have 
a more slowly developed bed-sore. An eruption of 
herpes, bullae, or pemphigus may appear on the limbs. 

The nerves arising from the part of the cord affected 
and the muscles supplied by them undergo destructive 
degeneration, and there may be wasting of the limbs, 
appearing more or less rapidly. The electrical reaction 
is affected under these circumstances, there being the 
reaction of degeneration. 

Above and below the principal focus of disease there 
will be secondary degeneration if the patient lives long 
enough. Then there may be found the exaggerated 
tendon reflexes and other symptoms belonging to lesion 
of the lateral pyramidal tracts. 

This description has been rather that of a severe 
case, which runs its course to a fatal termination. Fre- 
quently the symptoms are less grave : sensation is not 
entirely abolished in the legs ; the reflexes are not ab- 
solutely lost ; perhaps one side is chiefly affected, the 
other slightly so ; after a variable length of time there 
is a recession of the symptoms, the disease has ceased 



ACUTE MYELITIS. 185 

to advance, and the patient is recovering. The recov- 
ery is almost never complete. There generally remains 
some impairment of function. 

As an unusual complication may be mentioned op- 
tic neuritis, occurring at the same time or just preced- 
ing subacute myelitis, as observed by Erb. He thinks 
that the optic nerves and the spinal cord are both easily 
affected by the same injurious influences, and so may 
together be attacked with subacute inflammation. 

Diagnosis. — It is necessary to distinguish acute 
myelitis from meningitis, haemorrhage, and acute as- 
cending paralysis. 

It is also desirable to form an opinion as to the part 
of the cord affected. 

In meningitis there is much more severe pain, both 
in the limbs and back — such pain as to cause the pa- 
tient to complain of it bitterly ; this pain is increased 
upon motion. There is often great hyperaesthesia of the 
limbs ; fever runs higher in meningitis than in myelitis ; 
reflex actions are much more exaggerated and the con- 
tractions are more constant, and the limbs may be 
flexed, or there may be opisthotonus. Paralysis is a 
later symptom in meningitis ; trophic disturbances of 
the skin are rare. 

Haemorrhage is distinguished by the suddenness 
with which the initial symptoms arise, without fever, 
the injury preceding the disease, or, if spontaneous, the 
severe pain preceding or attending the commencement 
of the attack. The stationary character of the symp- 
toms after the first attack, or their gradual extension 
secondarily, also when the cervical and lumbar enlarge- 
ments are the seat of the haemorrhage, the rapid wast- 
ing and loss of electrical reaction, aid in forming a diag- 
nosis. If, however, the history of the case is imperfect, 
a diagnosis may be extremely difficult. 

Acute ascending paralysis may be diagnosticated by 
the fact that sensation is little if at all affected ; the 
bladder and rectum are not likely to be disturbed ; 



186 DISEASES OF TEE SPINAL CORD. 

there is no bed-sore ; the muscles do not undergo atro- 
phy. 

The diagnosis of the seat of the lesion must be made 
from a study of the symptoms, keeping in mind the 
physiology of the cord. Unilateral acute myelitis is 
almost never seen, excepting as the result of injuries, 
and need not be specially considered. In most instances 
the central gray substance is first affected ; the dis- 
ease spreads then to the white substance. If the an- 
terolateral columns are first affected, there will be 
loss of motor power, and, if the disease begins in the 
pyramidal tracts, the symptoms of lesion of those tracts. 
A much less extent of disease of the motor tracts will 
cause paralysis of motion than is necessary to give rise 
to loss of sensation ; indeed, if but a small portion of 
the gray substance is left, sensation is not entirely de- 
stroyed. 

Myelitis is much more common in the dorsal region, 
possibly explained by its vascular supply being less 
sure, as pointed out by Adamkiewicz. 

An examination of the reflexes, as suggested by 
Gowers, will aid in fixing the upper limit, and some- 
times the lower limit, of the disease ; so will a careful 
study of the muscles paralyzed and of the region af- 
fected with anaesthesia, by which means we can recog- 
nize what nerves have lost their function. 

Peognosis. — When myelitis begins violently and 
the paralysis advances rapidly, the prognosis is un- 
favorable; the same is true when the disease has 
reached or has commenced in the cervical region, and 
especially if respiration is disturbed. If there is much 
cystitis, or if bed-sores form, the prognosis is unfavor- 
able, even if other symptoms seem mild, and the more 
so if the general health suffers severely and if the pa- 
tient's constitution seems undermined. It is, however, 
often impossible to convince either the patient or his 
friends that he must die, so little discomfort does he 
experience. 



ACUTE MYELITIS. 18? 

The more gradual the advance of the disease, and 
the more incomplete the loss of function, the more 
favorable is the prognosis. A slight remission of symp- 
toms and sustained general strength are also favorable. 

Even when the patient has apparently nearly re- 
gained his health, a relapse is possible, and, after one 
attack, a slight imprudence may cause another, so that 
the patient must take extra care of himself. 

Teeatmejstt. — As soon as the disease is recognized, 
the patient should be put to bed and kept there. As 
perfect rest of mind and body as possible is absolutely 
necessary, even against the protest of the patient, who 
may be conscious of only slight numbness or weakness. 

Ice-bags to the spine, applied continuously, are of 
benefit in meningitis, and may be used in myelitis, 
though their value is less certain. A mild form of 
counter-irritation, dry-cupping, is of value, and should 
be employed ; two to six or eight cups can be applied 
daily ; usually two are sufficient, changing their place 
each time. The cups should remain on about half an 
hour, and should leave the skin much congested when 
removed. If the attack is very severe, the danger of 
bed-sores may contra-indicate cupping. 

Ergot, drachm doses of fluid extract, or six or eight 
grains of ergotin, should be given three times a day. 
This may be combined with one of the preparations of 
belladonna. 

Iodide of potassium may be used even in the earlier 
stages with advantage, and later even more efficacious- 
ly, especially where syphilis is suspected, and in those 
cases mercury may be combined with it. 

The greatest care should be taken to sustain the pa- 
tient's nutrition, to relieve the bowels, to prevent cysti- 
tis and bed-sores. 

When the patient is recovering, electricity can be 
used to maintain the nutrition of the muscles ; this 
may be combined with massage, or the latter can be 
used alone. 



188 DISEASES OF THE SPINAL CORD. 

Counter-irritation to the back, actual cautery, and 
dry-cupping may be employed during recovery, but 
are of doubtful efficacy then. 

CHRONIC MYELITIS. 

Chronic myelitis sometimes succeeds acute myelitis, 
or may result from injuries. It may also follow expos- 
ure to cold, fatigue, and long-continued emotional dis- 
turbances ; the eruptive fevers and other acute diseases 
may be complicated with chronic changes in the spinal 
cord ; syphilis is a very common cause. In many cases 
it will be found that lead has been received into the sys- 
tem. So frequently is lead one element in the aetiology, 
that it should be sought for in every case. Arsenic may 
give rise to the same symptoms. 

Pathological Anatomy. — After death the spinal 
cord is sometimes found softened; more frequently, 
however, it is found firmer in consistency than normal. 
The seat of the inflammatory changes may vary in dif- 
ferent cases ; sometimes the gray substance is chiefly 
affected, sometimes the white substance, and more fre- 
quently both gray and white are affected ; sometimes 
the disease extends through the whole thickness of the 
cord, and sometimes only one half is affected ; again, 
only the periphery of the cord is diseased — chronic cor- 
tical myelitis, as it has been called. 

The microscopic changes vary according as the con- 
nective tissue (neuroglia) or the nerve-fibers and cells 
are chiefly affected. If the neuroglia is primarily dis- 
eased, we have thickening of the connective tissue with 
increase of its elements ; secondary to these changes 
the nervous elements gradually disappear. 

When the latter are chiefly affected, they rjass 
through changes similar to those found in acute mye- 
litis ; the neuroglia may be somewhat thickened, or it 
may apparently suffer no change. 

The walls of the blood-vessels are usually somewhat 
thickened. The tissue around the vessels may undergo 



CHRONIC MYELITIS. 189 

granular degeneration, and thus spots of softening may 
form. 

Symptoms. — The symptoms of chronic myelitis will 
vary somewhat according to the seat of the lesion. 
The first symptoms may appear either in the sensory or 
motor function ; the motor phenomena consist in a 
gradually increasing weakness, affecting one or more 
limbs, the first sign of failure being a sense of heavi- 
ness in the legs or arms, and an unusual liability to 
become fatigued. These symptoms slowly increase in 
severity, the weakness becomes more marked, and the 
patient may be confined to his bed many months be- 
fore there is entire paralysis. There are rarely spasms ; 
but chronic contractures are not so infrequent, the legs 
being held in extension and adducted, rarely flexed. 
Reflex actions are sometimes moderately exaggerated ; 
this is often shown simply by an increase of the pre- 
existing contraction : thus, if it is desired to draw off 
the water, the introduction of a catheter may increase 
the adduction of the thighs so as to render the opera- 
tion very difficult, especially in a female. The tendon 
reflexes are sometimes exaggerated and sometimes di- 
minished, according to the location of the disease. 
When the anterior gray substance is affected, there is, 
of course, wasting of the muscles, in which case the 
electrical phenomena undergo the usual changes ; other- 
wise the electrical reactions may even be exaggerated. 

Disturbances of sensation appear very early, and are 
often the first symptom to attract the patient's atten- 
tion. These disturbances are often simply a sense of 
numbness and tingling, as if the limbs had been asleep, 
without any disturbance of tactile sensibility ; but 
sometimes the sense of touch is affected, and there is 
more or less marked anesthesia. Pain is not very 
common, but is occasionally very severe. In some cases 
there is hyperesthesia to touch, or the sense of touch 
is perverted so as to give rise to a peculiar vibrating 
pain. This sensory disturbance may remain limited to 



190 DISEASES OF THE SPIFAL COED. 

one limb, to a toe or finger, during several weeks be- 
fore extending, or before other symptoms appear. 

The condition of the bladder and rectum varies ac- 
cording to the seat of the lesion. There is danger of 
cystitis when urine is retained, as in the acute form. 
The sexual function is gradually abolished, though 
occasionally the sexual appetite may be increased. 
After the patient is confined to bed, bed-sores are liable 
to form, especially if cleanliness is neglected. 

The disease is slowly progressive toward a fatal ter- 
mination, but there are occasionally periods of remis- 
sion and improvement which may be so great as to 
encourage the hope of final recovery ; but some imj^ru- 
dence or exposure starts up the inflammation again, 
and causes an aggravation of the symptoms. Death 
may not occur for several years after the commence- 
ment of the disease. 

Diagnosis. — In well-marked cases this form of 
myelitis is not likely to be mistaken for other diseases 
of the spinal cord ; but in some instances it may be 
doubtful whether there is locomotor ataxia, multiple 
sclerosis, lateral sclerosis, or disease of the anterior 
cornua. When multiple sclerosis affects chiefly the 
spinal cord, it may be impossible to make a correct 
diagnosis. 

Vulpian says: "Every time there is found in a 
chronic affection of the cord an irregular course of the 
disease — causing weakness and paralyses of different 
parts of the body, giving rise to combinations of symp- 
toms belonging some to one systematic lesion, some to 
another, and presenting, as a whole, symptoms which, 
except for the rapidity of their appearance and their 
succession, would be more or less similar to those no- 
ticed in acute diffuse myelitis — it may be asserted that 
it is a case of chronic diffuse myelitis. 

"Whenever, in any. chronic affection of the cord, 
the assemblage of symptoms allows the elimination of 
systematic lesions, of sclerosis in patches, of chronic 



CHRONIC MYELITIS. 191 

myelitis of the anterior cornua, the case is one of 
chronic diffuse myelitis." 

Prognosis. — The disease is one of long duration 
and, as has been said, with periods of remission and 
improvement. Complete recovery is extremely rare, 
except in cases caused by lead or those occurring after 
fevers ; it probably never occurs, there always being 
some impaired function remaining to show that mis- 
chief has been done to the cord. 

In judging whether there is immediate danger to 
life, the circumstances of each case must be taken into 
account, and no general directions can be given. 

Treatment. — Active measures, such as are used in 
acute myelitis, would be entirely out of place in chronic 
myelitis. 

Dry- cupping, the actual cautery, the iron being 
heated to a white heat and drawn rapidly and lightly 
over the back, so as to simply char the cuticle without 
producing suppuration, small blisters applied in suc- 
cession along the spine, and iodine, may be employed 
as counter-irritants ; of these, the best are dry-cupping 
and the actual cautery. Brown- Sequard recommends 
a douche of hot water to the back, the application be- 
ing made for two or three minutes every day. 

The galvanic current may be used, one pole being 
placed above, the other below the probable seat of the 
disease ; the direction of the current may be varied at 
different sittings, both electrodes being held stationary, 
or one moved slowly up and down the back ; rather a 
weak current should be used, only for a few minutes at 
a time, the application being made daily, and the treat- 
ment persevered in for months. Sometimes this treat- 
ment will give rise to unpleasant symptoms ; it should 
then be discontinued. Erb says that he has obtained 
benefit in fifty-two out of one hundred cases treated by 
galvanism. 

Erb says : " The water-cure is, all things considered, 
one of the most important and most promising means 



192 DISEASES OF THE SPINAL CORD. 

of treating chronic myelitis. The mistrust with which 
it is regarded by some authors is, as far as my own ex- 
perience goes, entirely unjustifiable. It is suitable for 
most all cases, though, of course, the method of appli- 
cation must vary according to the peculiarities of the 
individual cases. 

" Simple rubbing with wet cloths, foot-baths, spong- 
ing the back, hip-baths, half-baths, with affusions to 
the back, local compresses to the back, left on till they 
become warm, etc., seem to be the measures which are 
chiefly applicable. The treatment should always be 
begun with moderate temperatures (20° to 25° C., or 
68° to 77° F.), and we should never go below 16° to 12° 
C. (60-£° to 53|° F.). I believe, also, that excessive pro- 
longation of the treatment is injurious." 

Of internal remedies, nitrate of silver, a quarter to 
half a grain three times a day for four or five weeks, 
then omitted for a short time ; ergot, half a drachm to 
a drachm of the fluid extract three times a day ; double 
chloride of gold and sodium, gr. -^ three times a day ; 
ext. of belladonna, gr. £ to £ twice or three times a 
day ; iodide of potassium should be used if there is 
lead, and anti-syphilitic treatment when it is indicated. 

In chronic myelitis there is less reason to keep the 
patient quiet and at rest than in acute myelitis ; yet 
over-exertion should be carefully avoided. It is much 
more prudent to restrain the patient's activity more 
than is necessary than to allow even a slight over-ex- 
ertion. The same may be said of all imprudent expo- 
sures to influences which are likely to cause the disease. 

ACUTE ASCENDING PARALYSIS. 

This is sometimes called Landry's paralysis, because 
Landry first described the combination of symptoms. 

It is defined by Erb as "a motor paralysis which 
generally begins in the lower extremities, spreads pretty 
rapidly over the trunk to the upper extremities, and 
usually also involves the medulla oblongata, which 



ACUTE ASCENDING PARALYSIS. 193 

sometimes runs its course without fever, sometimes 
with more or less active fever, which but slightly in- 
volves the general sensibility and the functions of the 
bladder and rectum, and which runs its course without 
notable atrophy of the muscles, and without any dimi- 
nution or change in their electrical excitability." 

This definition gives nearly the whole symptoma- 
tology of the disease. It is only necessary to add that 
prodroma, disturbed sensations, numbness, and aching 
in back and limbs, may precede the motor paralysis ; 
that the disease may commence in the upper extremity ; 
that reflex actions may be much diminished or entirely 
lost ; the tendon reflex has not been carefully studied ; 
and the functions of the brain do not seem disturbed 
until just before death. 

The disease usually ends fatally when the nerves 
arising from the medulla are affected. The symptoms 
may cease to advance at almost any stage, may recede, 
and the patient may recover. 

The symptoms recall those which are found in 
acute or subacute anterior poliomyelitis ; the reten- 
tion of electrical reaction in the muscles is the chief 
difference. 

Many cases have been examined after death, and no 
lesions discovered in the cord. 

When Landry described this form of paralysis in 
1859, the electrical reaction of muscles was not taken 
into account in forming a diagnosis, and there seems no 
special reason why that should be added in order to 
form a distinct disease. Several autopsies (Eisenlohr, 
Fox, v. d. Velden, Peabody) have lately shown that 
there are changes in the cord ; though these changes 
have seemed to be very slight, yet they have been quite 
diffused, and are such as may indicate an early stage 
of myelitis, sometimes affecting the white substance, 
sometimes the gray ; sometimes attended with no 
change in electrical reaction, sometimes accompanied 
with such change. No case has yet been reported in 

13 



194 DISEASES OF THE SPINAL COED. 

which a proper examination of the peripheral nerves 
has been made. 

The causes of this form of paralysis are said to be 
the same as those of myelitis ; the treatment should be 
the same as in acute myelitis. 

It is not my purpose to enter upon a long discussion 
of any doubtful points. In view of the cases which 
have been published, I can see no satisfactory reason 
for retaining acute ascending paralysis as the name of 
a distinct disease ; the cases coming under that desig- 
nation can be included under one of the forms of acute 
or subacute myelitis. 



CHAPTER XVI. 

POLIOMYELITIS.— MYELITIS OF ANTEEIOE COENUA. 

Petitfils, A., Considerations sur l'atrophie aigue des cellules 
matrices. Paris, 1873. — Gombault, Note sur un cas de paralysie 
spinale de l'adulte, suivi d'autopsie. Arch, de physiol., 1873. — 
Bernhardt, Ueber eine der spinale Kinderlahmung ahnliche Af- 
fection Erwachsener. Arch. f. Psych, u. NervenJcr., 1874, p. 370. 
— Bennett, A. H., On Chronic Atrophic Spinal Paralysis in Chil- 
dren. Brain, Oct., 1883, p. 289.— Seguin, E. C, Myelitis of the 
Anterior Horns. New York, 1877.— Proust, A., and Ballet, G., 
Contribution a l'anatomie pathologique de la paralysie generale 
spinale diffuse subaigue de Duchenne. Arch, de physiol., Oct., 
1883, p. 330. 

ACUTE ANTERIOR POLIOMYELITIS. 

This is the name that has lately been given to a class 
of diseases characterized by changes in the anterior cor- 
nua. These changes are generally considered to be of 
an inflammatory nature. 

The so-called infantile paralysis was for a long time 
the only recognized manifestation of this disease, but 
during the last ten years or so cases have been reported 
as occurring among adults having very nearly the same 
symptoms, and after death presenting similar lesions of 
the anterior cornua. 

It ought to be mentioned that some authors consider 
this affection primarily a disease of the muscles. This 
view is not generally accepted. Leyden refers the 
symptoms in some cases to a diffused or general neuri- 
tis. 

^Etiology. — By far the larger number of patients 



196 DISEASES OF THE SPIXAL CORD. 

are infants from one to three years of age ; among 
adults, the larger number are attacked between the 
years of twenty and forty; between the years from 
four to fourteen there seems to be comparative exemp- 
tion from this form of myelitis. During infancy both 
sexes are about equally liable to the disease ; among 
adults, males are rather more frequently attacked than 
females. 

During dentition the nervous system of a child is in 
a more irritable state, and perhaps more likely to suf- 
fer from injurious influences ; this may explain the fre- 
quency with which infantile paralysis occurs during the 
first and second years. 

Cold acting upon the surface of the body may be a 
cause of this form of myelitis as of other forms. In a 
very few cases I have been able to learn that during the 
night preceding the occurrence of the paralysis the child 
has been found to have kicked off the clothing, and 
thus become chilled. 

Falls and other injuries have sometimes seemed to 
be a cause. In adults, excessive exertion. 

The summer months show a larger proportion of 
attacks than the other seasons. 

Pathological Anatomy.— There are reasonable 
grounds for the opinion that the first change is a con- 
gestion of the anterior cornua, and perhaps of other 
parts of the cord also. In the foetus and in early in- 
fantile life the capillaries more closely surround the 
nerve-cells, each cell being inclosed in a net-work of 
small vessels. Adamkiewicz has shown that in the 
adult a system of canals, smaller than the capillaries, 
can be injected from the vessels so as to form a net- 
work, by which each nerve-cell is surrounded. After 
the first shock of the disturbed circulation, which 
causes the paralysis, the congestion diminishes, and 
with this the paralysis disappears, except where the in- 
jury to the nutrition of the cells has been sufficient to 
destroy or seriously impair their vitality. 



ACUTE ANTERIOR POLIOMYELITIS. 197 

Tbe essential change seems to be destruction of the 
nerve-cells ; other changes are either accidental compli- 
cations or secondary. When the patient has survived 
many years, the affected cornua are found deformed 
and diminished in size ; the neighboring white columns 
may also be misshapen. 

The anterior nerve-roots arising from the affected 
tract are atrophied and contain degenerated nerve- 
fibers, or the libers may have so entirely disappeared 
that simply connective tissue remains. 

The muscles undergo change at a comparatively 
early period. The muscular fibers lose their transverse 
striation, are broken up into granular and fatty debris ; 
sometimes the muscular nuclei are increased in num- 
ber ; the granular and fatty materials are absorbed, and 
there remains only the sarcolemma with a larger or 
smaller number of muscular nuclei. Sometimes, instead 
of undergoing atrophy, the muscles suffer from a waxy 
or colloid change, in which the fibers may be greatly 
enlarged. The interstitial tissue is usually increased 
in amount, and often fat is deposited between the mus- 
cular fibers. 

The bones of the affected limbs grow less rapidly 
than the corresponding healthy limbs, when the patient 
is a child. In adults there is no atrophy of the bones. 
Observations are not yet sufficiently numerous to deter- 
mine whether the bones become brittle. 

Symptoms. — In children the disease begins sudden- 
ly, sometimes, though rarely, with convulsions. Most 
frequently the child, having been put to bed apparently 
in good health, is somewhat restless during the night, 
perhaps awakes and cries, then sleeps quietly until 
morning ; in the morning it is discovered that one or 
more limbs are paralyzed ; generally one or both legs 
are affected ; sometimes the paralysis is confined to one 
or both arms, or an arm and a leg ; very rarely are the 
four limbs affected. The loss of power may not be 
complete at first, but it reaches its height in a very few 



198 DISEASES OF THE SPINAL COED. 

hours. The right leg is said to be the most frequently- 
affected. Sensation does not appear to be much dis- 
turbed ; except at the very beginning, there seems to 
be no pain, and it is doubtful if there is pain even at 
the beginning. Occasionally a slight febrile attack pre- 
cedes the development of paralysis ; but often this is so 
slight, especially in very young children, and of such 
short duration, as to attract little or no attention, and 
the severity of the succeeding paralysis is not propor- 
tionate to the amount of fever. 

When convulsions usher in the attack, they are 
usually of short duration and differ materially from the 
severe convulsions of cerebral origin preceding many 
cases of hemiplegia in infants. 

Within a few days, from two or three days to one 
or two weeks, an improvement in the paralysis is no- 
ticed, which may, in light cases, advance to complete 
recovery, though more frequently the improvement 
ceases after a few weeks, leaving some muscles still 
paralyzed. Where more than one limb is affected, the 
muscles of one limb may entirely recover, while those 
of the other limb or limbs only partially recover. 

Within a short time after the paralysis appears, the 
muscles begin to undergo the atrophic changes already 
mentioned, and after a few weeks the affected limb 
shows decided evidence of wasting. Its growth is also 
retarded, and after some years there may be a differ- 
ence of from one to six or seven inches in the length of 
the legs. Erb says that, while the atrophy is progress- 
ing, the muscles are quite sensitive on pressure. 

The affected muscles show a change of electrical 
action — reaction of degeneration — within a few days 
(four or five) after the attack. 

The skin may be dry and scaly, and the circulation 
sluggish, on account of which the limb is cold and more 
or less cyanotic. Bed-sores do not form, nor is it likely 
that herpetic and allied forms of skin eruption are 
caused by this disease. 



ACUTE ANTERIOR POLIOMYELITIS. 199 

The reflexes, cutaneous and tendinous, are more or 
less disturbed according to the amount of muscular 
paralysis. 

After months or years, sooner or later, according to 
the amount of wasting, deformities result. Where there 
is inequality of the limbs, the bones of the pelvis are 
tilted and the spine is curved. The affected limb suf- 
fers also from contracture ; club-foot and deformity of 
the knee and hip joint are seen. The upper limbs are 
much less frequently subject to contracture and de- 
formity than the lower limbs. Erb divides the causes 
for these contractures into three classes : 1. "The most 
frequent cause is the continued approximation of the 
points of attachment of the muscles, induced partly by 
the weight of the parts, partly by external pressure in 
walking, standing, etc." 2. "The antagonists of the 
paralyzed muscles remain effective." 3. "The prolif- 
eration of interstitial connective tissue and its subse- 
quent retraction, which takes place with the degenera- 
tive atrophy of the muscles." 

After the first febrile attack, the bladder and the 
rectum are not affected, and all the functions of the 
body, except those of the paralyzed limbs, are normally 
performed. Life is not shortened by this disease, and 
the mental powers of the child are, as a rule, not af- 
fected. 

In adults the course of the disease is somewhat dif- 
ferent from that noticed in children ; as with other 
febrile affections, convulsions are absent ; pain is a 
rather more prominent feature ; febrile reaction is 
rather more marked, though it may be absent ; the pa- 
ralysis is developed rather more slowly ; sensibility is 
more frequently disturbed at the beginning, though 
this usually soon disappears ; occasionally vomiting 
and gastric disturbances are noticed. After some days 
or weeks, longer than with children, the paralysis 
amends, and, as in children, there may be complete 
recovery, though partial recovery and wasting are the 



200 DISEASES OF THE SPINAL COED. 

more frequent result. Of course, there is in adults no 
retarded development, and subsequent deformity is 
much less than in children. The electrical reaction 
and other symptoms are almost identical. 

Diagnosis. — The disease which has been most fre- 
quently confounded with acute anterior poliomyelitis 
in children is hemiplegia from cerebral cause. In this, 
convulsions are much more frequent and severe, the 
paralysis is hemiplegic rather than paraplegic, the elec- 
trical reactions remain unchanged, contractions resem- 
ble the hemiplegic contractions found in adults, and 
there may be post-hemiplegic chorea; the growth of 
the paralyzed limbs is much more retarded. 

Hemorrhage into the spinal cord, though occurring 
suddenly without febrile reaction and followed by 
change in the electrical phenomena, may be recognized 
by the initial pain which usually attends it, by the dis- 
turbance of sensation, and the subsequent progress of 
the case, even partial recovery being much slower and 
more tedious. The history of the case ought to lead to 
a correct diagnosis from other diseases. 

Prognosis. — The prognosis, so far as life is con- 
cerned, is favorable. Complete recovery of motion in 
the paralyzed limbs can be expected only in very mild 
cases, and even in such, more frequently than not, 
when the child is tired there will be a slight awkward- 
ness in using the affected limb. Generally the recov- 
ery is imperfect. After five or six months all is gained 
that can be expected. If proper treatment is pursued, 
a much larger amount of motion can be recovered than 
when the child is left without treatment. 

Nothing can be done to prevent retardation of 
growth, but deformities resulting therefrom may be at 
least partially prevented by mechanical appliances. 

Treatment. — In the first stage the fever may be 
combated with the ordinary measures, and, if a diagno- 
sis can be made out early, ergot, belladonna, and iodide 
of potassium may be given in rather large doses ; coun- 



ACUTE ANTERIOR POLIOMYELITIS. 201 

ter-irritation is also indicated, dry cups and the actual 
cautery being the most desirable forms ; as Seguin sug- 
gests, tincture of iodine and blisters cause too much 
pain and make the skin sore. 

After the fever has ceased, and in cases where there 
is no fever, when time enough has elapsed to guard 
against unfavorable reaction, electricity should be used. 
The galvanic current should be used from the begin- 
ning, even if the muscles respond to the faradic cur- 
rent ; the positive pole or anode should be placed on 
the spine near the origin of the nerves leading to the 
affected muscles ; the negative pole, cathode, should be 
passed slowly over the muscles, or, the motor point for 
each muscle having been found, the cathode may be 
placed there, and the current may be slowly interrupt- 
ed. Only such strength of current need be used as will 
cause perceptible contraction in the muscles. The ap- 
plication should be made every day or every other day 
for about one minute to each muscle. The reaction of 
degeneration may appear while the electricity is being 
used, if its use is commenced early. 

In order to obtain benefit from the use of electricity, 
it must be continued for months ; a short treatment of 
a few weeks, except in very mild cases, would proba- 
bly be of little value. To obtain the best results, it 
should be used as soon as possible after all symptoms 
of irritation have ceased. 

With children, a little caution may be necessary in 
order not to frighten them at the beginning by the nov- 
elty of the application ; also a very mild current should 
be used until they are accustomed to the peculiar sen- 
sations. 

Bathing the affected limbs in hot water is of advan- 
tage, allowing them to remain immersed for several 
minutes ; then the limbs should be rubbed and knead- 
ed for several minutes. The warmth of the limbs must 
be maintained by proper clothing or other means. 
Over-exercisino: of the limbs should be avoided : bath- 



202 DISEASES OF THE SPIXAL CORD. 

ing and rubbing should not follow too closely after the 
use of electricity. 

After all hopes of further improvement have to be 
laid aside, much assistance can sometimes be given by 
orthopaedic surgery and mechanical appliances. 

Except in the first stage, no advantage can be gained 
from the use of medicines internally. Hypodermic in- 
jections of strychnia into the affected muscles have been 
recommended ; but it is very doubtful whether more 
can be gained in this way than by the persevering use 
of electricity. 

CHRONIC ANTERIOR POLIOMYELITIS. 

Attention has been called within only a few years 
to a form of atrophic paralysis which closely resembles 
acute poliomyelitis, yet is, in some respects, different, 
the attack being less abrupt, the symptoms not exactly 
the same. Duchenne, in 1872, and Erb, in his volume 
on the spinal cord, in Ziemssen's " Cyclopaedia, " in 
1877, gave detailed descriptions of the disease, under 
the name of poliomyelitis anterior subacuta or chron- 
ica. Since then many cases have been reported, some 
authors preferring to call it subacuta rather than chron- 
ica. As in regard to several other forms of nervous 
diseases, it seems that it was only necessary to have at- 
tention called to its peculiar symptoms in order that 
many cases might be recognized. 

E. C. Seguin has given a very careful study to both 
the acute and subacute or chronic form of lesion of the 
anterior cornua. 

When the cases included by different authors are 
compared, it will be seen that they are simply cases of 
chronic myelitis in which the anterior cornua, especial- 
ly its nerve-cells, are affected early in the course of the 
disease so as to give a special physiognomy to the 
symptoms. Except for some peculiarities in the course 
of the symptoms, it would not be desirable to give 
these cases a separate designation. 



CHRONIC ANTERIOR POLIOMYELITIS. 203 

.ZEtiology. — We must confess our ignorance of the 
cause of the disease in many cases ; in other instances 
chronic lead-poisoning seems to be the chief if not only 
cause ; certainly in several patients whom I have seen 
with this assemblage of symptoms there was lead in 
the system. Injuries and chills may be the starting- 
point in this as in other forms of myelitis. Most of the 
patients are adults. I have, however, seen one child 
twelve years old with the disease, and an infant seemed 
to have at first acute poliomyelitis, but later the disease 
followed a chronic course. It may occur in aged per- 
sons also, though rarely. 

Pathological Anatomy. — Very few autopsies 
have been made — only five or six. In nearly all of 
these, other parts of the cord than the gray anterior 
cornua were diseased. In a case reported by Baumler, 
the only change found was in the gray substance. 
There is atrophy and destruction of the cells of the 
anterior cornua ; the nerves and muscles undergo cor- 
responding degeneration. Other portions of the cord 
than the cornua may also be affected, and thus would 
be explained variations in symptoms, the chief lesion, 
and that which gives its name to the disease, being, 
however, constant ; the other lesions are variable. 

Symptoms. — The more marked features of the dis- 
ease are found among the motor functions. The patient 
finds a difficulty in following his usual occupation on 
account of weakness, which may be noticed first in the 
lower or upper extremities, usually the former. After 
a longer or shorter time this weakness increases until 
there is paralysis ; sometimes one limb alone is at- 
tacked, or both arms or legs may be ; at length the 
paralysis extends to those limbs not previously affected. 
The reflexes are diminished and lost in proportion to 
the severity of the paralysis. Inco-ordination is rare. 

When time enough has elapsed, the affected muscles 
will be noticed to have wasted, unless, as occasionally 
happens, the increase of fat conceals the atrophy, or a 



20± DISEASES OF TEE SPIXAL CORD. 

sclerotic degeneration of the muscular fibers enables 
them to keep their size while losing their distinctive 
muscular character ; they will then be felt as hard re- 
sisting masses. 

The electrical reactions show the changes due to de- 
generation of nerves and muscles. These changes will 
depend somewhat upon the progress of the disease and 
the amount of structural changes. Yet very careful 
observations made by Kahler and Pick show that there 
is no absolute relation between the electrical reactions 
and the loss of voluntary power. The muscles may 
show reaction of degeneration, yet may contract under 
the influence of the will. In the case recorded by Kah- 
ler and Pick there was a steady diminution of the fara- 
dic contractility, until nearly all the muscles of the 
limbs, body, and face were thus affected, even while 
the voluntary control was improving. This anomaly is 
the more frequently seen during restoration of the mo- 
tor functions. 

The progress of the disease may be arrested at any 
period ; then, after an interval, either the symptoms 
may be aggravated or, more frequently, the power may 
slowly return ; occasionally the recovery is complete, 
more frequently it is only partial. 

The above are the constant and essential symptoms. 
Other phenomena depend upon what other parts of the 
cord are diseased. 

When the pain is severe, there is probably a limited 
meningitis. It is more common to have soreness of the 
muscles, especially before any aggravation of motor 
symptoms. Numbness, tingling, and a sense of weari- 
ness may precede and accompany the earlier motor dis- 
turbances. Cutaneous sensibility is, as a rule, only 
slightly diminished, and is often not affected. 

Patients are rarely seen at the very commencement 
of the disease, so that the symptoms at that period are 
only occasionally studied ; fever is sometimes present, 
but is • not very marked. The limbs which are para- 



CHRONIC ANTERIOR POLIOMYELITIS. 205 

lyzed, and yet more if atrophy has set in, are generally 
cold and may be cyanotic. 

The bladder and rectnm are rarely affected. There 
are no bed-sores. The ordinary functions of digestion 
are not disturbed. Cerebral symptoms are absent, ex- 
cept, in a few instances, nystagmus. 

Diagnosis. — It is scarcely necessary to recapitulate 
the symptoms in acute anterior poliomyelitis for the 
sake of diagnosis. 

It is quite probable that formerly chronic anterior 
poliomyelitis was confounded with progressive muscu- 
lar atrophy. The latter is more slowly progressive ; 
the paralysis or weakness appears after the atrophy or 
about the same time ; the reaction of degeneration is 
wanting or is much less clearly marked ; the reaction 
to both the faradic and the galvanic currents decreases, 
though the latter may persist longer than the former. 
In the progressive atrophy certain muscles are attacked 
by preference, and there is rather an irregularity in the 
progress of the affection ; it seems to jump from one 
region to another, leaving intermediate muscles unaf- 
fected. There is less likely to be remissions or cures ; 
the reflexes persist. 

Prognosis. — A large proportion of the patients 
either regain a certain amount of motor power, or, more 
rarely, recover. The tendency is toward remission. 

The course of the disease is long and slow, and years 
may elapse before it can be said that all the gain pos- 
sible has been made. 

A few cases of death have been recorded, showing 
that life is not always spared. Of course, if the disease 
affects the medulla oblongata or the respiratory centers, 
the prognosis must be unfavorable. 

Treatment.— When lead seems to be a cause, iodide 
of potassium should be given at once. If, after a week's 
use of that drug, lead can be found in the urine, it should 
be continued for months. Some advise large doses in 
order to eliminate the lead quickly. The advantage is 



206 DISEASES OF THE SPINAL COED. 

doubtful ; it is frequently necessary to be cautious lest 
symptoms of acute lead - poisoning should appear. 
Sometimes one or two grains are as much as can be 
given. 

Early in the disease, or when there are exacerba- 
tions, ergot and belladonna may be given as in acute 
myelitis. 

If the pain is severe, morphia or atropia may be ne- 
cessary, or the galvanic current may be found sufficient 
to relieve the pain. 

The galvanic current should be applied to the spine 
even early if there is no fever ; positive pole above, 
negative below. A current from six or eight cells, such 
as will not cause discomfort, can be used daily, or every 
other day, for five minutes at a time. Later the para- 
lyzed muscles should be stimulated to contraction by 
the direct application of the electrode to them, the cur- 
rent being interrupted. The faradic current is less effi- 
cacious. 

Counter -irritation to the back, blisters, dry cups, 
or, better than either, the actual cautery, may be of 
great benefit. 

Kest in bed while the disease is advancing is desir- 
able. If its progress is slow, it may not be necessary, 
however, to stay in bed all the time. As the muscles 
are regaining power, care should be taken not to over- 
tax them by too prolonged or too severe use. 

Massage and warm bathing, not too warm, are use- 
ful adjuncts as a means of maintaining the nutrition of 
the limbs. 



CHAPTER XVII. 

PROGRESSIVE MUSCULAR ATROPHY. 

Friedreich, N., Ueber progressive Muskelatrophie. Berlin, 
1873. — Charcot et Gombault, Note sur un cas d'atrophie mus- 
culaire progressive spinale protopathique. Arch, de physiol., 
1875, p. 736.— Sturge, Allen. Lancet, May 21, 1881, p. 828.— 
Fox, A. W. , Case of Progressive Muscular Atrophy with. Bulbar 
Paralysis. Brit. Med. Jour., Jan. 15, 1881, p. 82. — Clarke, J. L. 
Arch, of Med., London, 1863, p. l.—Med. Chir. Trans., 1873, p. 
103. 

Zimmerlin, Franz, Ueber hereditare (familiare) progressive 
Muskelatrophie. Zeitschr. f. M. Med., vii, 1883, p. 15.— Erb, W., 
Ueber die juvenile Form der progressive Muskelatrophie. Dent. 
Arch.f. M. Med., xxxiv, 1884, p. 467. 

Three theories have been advocated in regard to the 
nature of this disease : That it is primarily a muscular 
affection, the changes in the nervous system being sec- 
ondary ; that it is a disease of the sympathetic system ; 
that the seat of the disease is in the spinal cord. The 
question as to which of these is the correct theory has 
not yet been settled, and I have not the data upon 
which to form a final opinion. I give it a place among 
lesions of the spinal cord because constant changes have 
been found in the cord, and because it seems useful to 
place it alongside of other affections which somewhat 
resemble it. 

Etiology. — As the first symptoms appear gener- 
ally in those muscles which are most used, it is proba- 
ble that excessive use acts as one cause, at least as the 
cause for localizing the disease at the beginning. 

Men are more frequently attacked, and middle adult 



208 DISEASES OF THE SPINAL CORD. 

age is the most favorable for the development of the 
disease. 

At least sometimes heredity seems to be an impor- 
tant ^etiological factor. 

There is a close resemblance between progressive 
muscular atrophy and pseudohypertrophic paralysis, 
in that brothers are frequently attacked, and the dis- 
ease seems to be transmitted through the females of a 
family. 

Pathological Anatomy. — Unfortunately, it is im- 
possible to give a satisfactory account of the post- 
mortem changes connected with the nervous system, 
because in many cases the examination has been im- 
perfect. 

The spinal cord has been frequently found either 
normal or with very slight changes, not always affect- 
ing the cells. In some of the cases where there was no 
change, the question has been raised whether they were 
cases of progressive muscular atrophy. 

In a large number of cases the cells of the anterior 
cornua have been found diseased, atrophied. 

In a very few cases, comparatively, the sympathetic 
has been found diseased. In many more it has been 
examined and no disease found. In a large number of 
cases, even where the cord has been healthy, the sym- 
pathetic has not been examined. 

The weight of evidence to the present time is in 
favor of the seat of the disease being in the cord ; but 
it is necessary that more examinations should be made 
of thoroughly typical cases before the question can be 
decided. 

The changes in the muscles are only occasionally of 
an active nature ; they are rather regressive in charac- 
ter. In many fibers there is a tendency to split up lon- 
gitudinally ; much less frequently they separate trans- 
versely. Frequently there is a simple atrophy ; some- 
times a waxy degeneration or a fatty degeneration can 
be recognized. 



PROGRESSIVE MUSCULAR ATROPHY. 209 

The nuclei of the muscles may be increased quite 
early, and sometimes the sarcolemma sheath is filled 
with these nuclei after the contractile substance of the 
muscular fiber has disappeared. Finally the proper 
muscular structure disappears, and there remains only 
a fibrous-like substitute in place of the muscle. 

An increase of the interstitial tissue with, or less 
commonly without, deposit of fat may proceed uni- 
formly with the degeneration of the muscles, or may 
even advance so rapidly as to give the muscles an ap- 
pearance of having undergone hypertrophy. 

Symptoms. — The atrophy from which the disease 
takes its name, with the attending weakness and pa- 
ralysis, is the principal symptom. The wasting is 
almost or quite imperceptible in its beginning, pro- 
gresses very slowly, and may have advanced so as to 
seriously interfere with the use of the limb before it is 
noticed. The patient is aware, perhaps, for a short 
time of a slight loss of skill or readiness in his motions, 
or that he is more quickly tired than usual ; then he 
finds that he is unable to use his hands or arms with 
natural ease and strength ; then notices the change in 
configuration, and may think the whole has occurred 
within a few hours ; yet, on closely questioning him, it 
will be discovered that several weeks at least have 
elapsed since the first slight symptom appeared. 

A large majority of patients are first attacked in the 
hands or arms ; usually the muscles of the thenar or 
hypothenar eminence, the interossei and lumbricales, 
are the first to undergo atrophy, and the right hand or 
arm is much the more frequently affected first. Authors 
disagree as to whether the atrophy attacks the interos- 
sei or the muscles of the thenar eminence first. The 
position of the fingers is peculiar when the disease has 
made considerable progress. There is the claw-shaped 
hand. The thenar eminence is thinned, leaving a flat- 
tened, slightly concave surface in place of the normal 
convex swelling of the ball of the thumb. 

14 



210 DISEASES OF THE SPIXAL COED. 

Next to the small muscles of the hand, the flexors 
and supinators of the forearm, or the deltoid, are at- 
tacked ; then other muscles connected with the scapula 
and those of the trunk, and finally the muscles of the 
lower limbs, may be affected. The progress of the dis- 
ease from muscle to muscle observes no regular order, 
but muscles widely separated may be attacked before 
the intermediate muscles suffer. 

Generally both sides are affected nearly at the same 
time, though often several days or weeks elapse before 
the second side is attacked. The rate of progress dif- 
fers very widely ; there may be long intervals when the 
symptoms remain stationary. 

Very rarely the disease may begin with the lower 
limbs— either in the thighs or the legs — though Eulen- 
burg thinks this form occurs only among children in 
a form allied to pseudo-hypertrophic paralysis. 

As the power of motion is not lost until the muscles 
have almost entirely disappeared, the patient may be 
able to move his limbs even when there is great emacia- 
tion. When the atrophy has advanced far, so that a 
large number of muscles, both those of the limbs and 
of the trunk, are greatly wasted, he presents a pitiable 
appearance ; especially if the facial muscles have also 
been attacked ; he becomes a "walking skeleton," the 
bones apparently only covered by the integument. 

Even before a muscle is seen to waste, and while 
that process is going on, very slight and rapid contrac- 
tions of individual muscular fibers can be seen, which, 
occurring repeatedly in the same or adjoining bundles 
of fibers, produce what is called fibrillary contractions. 
These may be compared to the fitful flashing sometimes 
seen as the light of the aurora spreads over the sky. 
If these contractions do not appear spontaneously, they 
may be excited by giving the muscles a fillip with the 
finger or a pencil. By observing this phenomenon in 
muscles not yet wasted, it is often possible to foretell 
which will be next attacked. 



PROGRESSIVE MUSCULAR ATROPHY. 211 

The electrical reaction of both nerves and muscles is 
diminished in proportion to the amount of atrophy. 
The galvanic current will cause contractions longer than 
the faradic current. Rosenthal says that the nerve- 
filaments nearest the centers may react normally, while 
the peripheral ramifications may show diminished reac- 
tion. 

Remak discovered that when the negative pole is 
placed over the fifth or sixth cervical vertebra, and the 
positive pole is placed on the side of the neck in the 
carotid fossa, or in the triangle between the lower jaw 
and the ear, there follow contractions in the atrophied 
muscles on the side opposite that where the positive 
pole is when the current is interrupted. This reaction 
is most easily shown with the galvanic current, but it 
is not constant. If both poles are placed on the side of 
the neck, with a weak current, the contraction may be 
excited on both sides. Remak called this "diplegic 
contraction." He referred it to a reflex contraction ex- 
cited through the medium of the superior cervical gan- 
glion. Others do not agree with this view. 

Sensibility is usually not affected ; even when dis- 
turbed, the change is very slight. Pain, however, in 
the affected muscles is not uncommon ; this pain may 
be excited by motion or by pressure, and it is some- 
times spontaneous. Cutaneous reflexes are sometimes 
heightened, especially in the early stages. The patel- 
lar tendon reflex has been found present in a case 
where the muscles of the legs and thighs were not atro- 
phied ; in another case slightly diminished. It is some- 
times exaggerated, its strength depending upon the 
state of the muscles which contract in response to the 
stimulus. 

The temperature of the affected limbs is sometimes 
at first moderately elevated, but later it is lowered. 
The joints may be swollen and painful, more particu- 
larly the smaller joints. There may be bed-sores to- 
ward the close, unless some intercurrent disease short- 



212 DISEASES OF TEE SPINAL COED. 

ens life. Occasionally herpes and changes in the hair 
and nails are to be noticed. 

The pupils may not be symmetrical, and there may 
be a variation in their relative size, but in very many 
patients there is no deviation from the normal con- 
dition. 

The disease slowly advances, with occasional pauses, 
more muscles being invaded, until the patient is help- 
less. The duration may extend over two to twenty 
years. Finally respiratory muscles, or those of deglu- 
tition, are affected, and the patient dies. 

Erb describes a special form of muscular lesion, 
which he calls the "juvenile form of progressive mus- 
cular atrophy," consisting in part of hypertrophy with 
subsequent atrophy, with greater or less formation of 
fat tissue and increase of interstitial connective tissue. 
The same sets of muscles are attacked in different cases, 
especially the pectorales, cucullares, latissimi, flexor 
group on the arm, triceps ; forearm and hand are not 
affected ; in the lower limbs, those of the thigh, the 
peroneal region, and the calf are attacked ; also the 
lumbar extensors. There is no fibrillary tremor nor 
degenerative reaction. The disease begins in childhood 
or youth, and may be mistaken for progressive muscu- 
lar atrophy or pseudo-hypertrophy. 

Peognosis. — There is no immediate danger to life 
unless bulbar symptoms or disturbed respiration set in, 
but the prospect of cure is very slight. When seen 
early, it may be that the disease can be checked and 
even muscles restored ; but this is very rarely the result. 
As a rule, there is before the patient only a life of 
gradually increasing weakness, ending in total disabil- 
ity, which may be prolonged through years. 

Diagnosis. — The disease which has been most fre- 
quently confounded with progressive muscular atrophy 
is poliomyelitis — anterior, subacute, or chronic. The 
commencement and progress of the disease are much 



PROGRESSIVE MUSCULAR ATROPHY. 213 

more gradual in the former, the sensation is less fre- 
quently disturbed early in the disease, the electrical 
reactions are different, the paralysis is more propor- 
tionate to the atrophy, except when there is increase 
of fat, and the irregular order in which the muscles are 
attacked is quite characteristic. In many cases of the 
chronic anterior poliomyelitis, lead is found to be a fac- 
tor in causing the disease ; this has not yet been recog- 
nized in progressive muscular atrophy, though it was 
found in one of my patients. 

Local injuries to both muscles and nerves may simu- 
late progressive muscular atrophy, and wasting of mus- 
cles in consequence of joint disease may lead at first to 
doubt as to diagnosis, but careful study of the history 
and of all the circumstances will probably guard one 
from mistake. 

The local paralysis of the hands from lead, the wrist- 
drop seen in that aifection, can be recognized by the 
fact that the extensors are chiefly affected, and the in- 
terossei and the muscles of the thenar eminence escape ; 
the fact of exposure to lead, previous lead colic, the 
lead cachexia, and the condition of the blood, would aid 
in diagnosis. Yet once in a great while a case may 
occur which will require great care to decide correctly. 

Teeatment. — Internal remedies are not likely to be 
of much value. If, however, lead can be detected in 
the system, an effort should be made to eliminate it by 
using iodide of potassium. 

Electricity is of value — either the faradic or galvanic 
current — applied locally, so as to cause muscular con- 
tractions ; that current is to be chosen which will most 
readily cause the muscles to contract ; sometimes a very 
strong current will be needed. The galvanic current, 
of moderate strength, may be applied to the spine at 
the same time. 

Exercise should be restricted within the limits of 
fatigue. Patients are mistaken in supposing that by 
taking much exercise they can restore the strength of 



214 DISEASES OF TEE SPINAL COED. 

diseased muscles. It is necessary to caution them on 
this point. When the muscular power is much re- 
duced, and even before, Swedish movement is of value. 
Massage should be used from the beginning where it is 
practicable. 

These means for help should be used perseveringly 
through many months before discontinuing treatment. 
No benefit can be expected from a short treatment. 



CHAPTER XVIII. 

BULBAE PAEALYSIS (LABIO-GLOSSO-LARYNGEAL PARALY- 
SIS). 

Kussmaul, A., Ueber die fortschreitende Bulbai-paralyse und 
ihr Verhaltniss zur progressiven Muskelatrophie. Volkmann's 
Tel. Vortrdge, No. 54, 1873. — Strumpell, Adolf, Zur Casuistik 
der apoplektische Bulbarlahmungen. Dent. Arch. f. kl. Med., 
xxviii, 1880, p. 43. — Beevor, C. E., Case of Glosso-labial Paralysis 
witb Progressive Muscular Atrophy and Lateral Sclerosis. Brain, 
Oct., 1882, p. 403. — Leyden, E., Zur progressiven Bulbarparalyse. 
Arch. f. Psych, u. Nervenkr., ii, iii. — Finny, J. M., Clinical Re- 
marks on Cases illustrating the Essential Identity of Progressive 
Muscular Atrophy and Progressive Bulbar Paralysis. Brit. Med. 
Jour., June 14, 1884, p. 1132.— Bennett, A. H., Bulbo-spinal 
Atrophic Paralysis. Brit. Med. Jour., March 8, 1884, p. 647. — 
Eisenlohr, C, Ueber acute Bulbar- und Ponsaffectionen. Arch. ' 
f. Psych, u. Nervenkr., ix, p. 1, x, p. 31. — Ross, James, Labio- 
glosso-pharyngeal Paralysis of Cerebral Origin. Brain, 1882, p. 
145. — Kirchhoff, Cerebrale Glosso - Pharyngo - Labial - Paralyse 
mit einseitigem Herd. Arch. f. Psych, u. Nervenkr., xi, 1880, p. 
132. 

BULBAR PARALYSIS. 

Duchenne first called attention to the combination 
of symptoms which are known as bulbar paralysis un- 
der the name of glosso-labio-laryngeal paralysis. There 
is paralysis of the muscles with atrophy of the tongue, 
of the soft palate, of the lips, of the pharynx and lar- 
ynx ; muscular atrophy may also extend to other re- 
gions, until with the symptoms of bulbar paralysis 
there are united those of progressive muscular atrophy. 

Pathological Anatomy. — Muscles undergo the 
changes which are found in other cases of atrophy. 
The nerves, especially the hypoglossal, facial, and ac- 



216 DISEASES OF THE SPIXAL COED. 

cessory, exhibit the usual appearances of fatty degen- 
eration, such as are found in other cases of muscular 
atrophy of central origin. 

The medulla oblongata seems to be the primary seat 
of the disease. Often nothing abnormal can be recog- 
nized with the naked eye ; but under the microscope 
changes will be discovered in the motor nuclei of the 
medulla, The ganglion nerve-cells undergo degenera- 
tion and atrophy either with or without disease of the 
surrounding tissues. The nuclei of the hypoglossal, 
accessory, vagus, and that part of the facial nucleus 
connected with its inferior branch, are most frequently 
affected ; the nucleus of the glossopharyngeal nerve is 
less frequently affected. When the disease spreads so 
as to implicate the muscles of the extremities, the cor- 
responding parts of the spinal cord will also be found 
affected. 

JEtiology. — Of the causes of bulbar paralysis we 
know almost nothing. It is confined almost entirely 
to advanced life, and is more frequent among males ; 
but it has been seen as early as twelve years ; Erb saw 
it in a girl of twenty years. Syphilis, exposure to cold, 
and injuries have been mentioned as causes. 

Symptoms. — As with most chronic diseases of the 
spinal cord, the earliest symptoms are so insignificant 
as to be often overlooked or neglected. 

They vary in different cases according as the nucleus 
of one or another of the nerves of the medulla oblon- 
gata is chiefly or primarily affected. The hypoglossal 
nucleus generally suffers first, and in the majority of 
cases the first motor disturbance is noticed in the 
tongue. The patient is not able to move his tongue 
quite as freely as normal, and his articulation becomes 
imperfect. Some letters can not be readily pronounced ; 
e is first lost, then there is trouble in expressing the 
sounds r, sh, s, Z, £, g, t, and later d and n ; the mo- 
tions of the tongue, apart from speech, are interfered 
with, and it can not be protruded beyond the teeth ; 



BULBAR PABALY8IS. 21T 

the affection being bilateral, it is not protruded to one 
side, it is not moved forward, it can not be turned in 
the mouth to loosen food from between the gums and 
cheek, and it can not be formed with a trough-like de- 
pression in the center ; the tip can not be raised against 
the upper teeth, and the center or root of the tongue 
can not be arched to touch the hard and soft palate ; it 
can not be used to press food backward in the first act 
of deglutition. 

When the nucleus for the lower branch of the facial 
nerve is affected, the lips act less readily, and, if the 
disease begins thus, the letters in which the lips chiefly 
act are first pronounced indistinctly ; if the lips are 
affected later, then the power to pronounce those letters 
is lost later ; these letters are o and u first, later e and 
a ; of the consonants, p and f ; later b, m, and v are 
lost. When the lips can not be readily moved, there 
is much difficulty in keeping food in the mouth while 
eating ; the saliva runs out of the mouth. 

When the soft palate is paralyzed, which is only 
after the tongue or lips have been affected, the voice 
acquires a nasal tone, and the explosives can not be 
clearly pronounced, especially b and p. If the loss of 
power in the soft palate is considerable, drinks will re- 
turn through the nose, and, if it is extreme, even solid 
food will thus return. The glottis is not properly 
closed, and therefore food, or more especially drink, 
enters and excites paroxysms of coughing. The pa- 
tient gradually gives up drinking and tries to swallow 
only soft solids. 

The patient's countenance acquires a characteristic 
expression ; from the paralysis of the lower branches 
of the facial nerve the mouth and lower part of the face 
are motionless ; the lower lip is dragged down and rolls 
outward from its own weight ; the saliva acquires a 
more tenacious character, and, not being swallowed, 
collects and flows out at the corners of the half-open 
mouth. The tongue can not be protruded nor moved, 



218 DISEASES OF TEE SPINAL CORD. 

but lies on the floor of the mouth, atrophied and 
shrunken, constantly agitated by fine fibrillary tre- 
mors. The superior branch of the facial nerve is not 
paralyzed, and hence the forehead and eyelids move 
naturally. The ocular muscles are unaffected. 

Sensation is not disturbed, nor are the special senses, 
taste remaining intact. 

The disease advances slowly, sometimes with remis- 
sions, but as a rule steadily, until the patient at last is 
a pitiable spectacle, talking with extreme difficulty, 
perhaps unable to make himself understood ; intelli- 
gent, conscious of his condition, with bright and speak- 
ing eyes, he eagerly desires the food which he can not 
swallow, or, if he tries laboriously to swallow, is nearly 
strangled by choking. He necessarily becomes weak 
and emaciated from lack of nutrition ; but, apart from 
this cause of debility, it is not infrequent that the mus- 
cles of the extremities and even of the trunk suffer 
atrophy, as the disease of the motor cells extends to 
those in the anterior cornua of the cord ; thus general 
muscular atrophy is added to the local. The arms and 
neck are usually first the seat of this change. 

The pulse is sometimes irregular or rapid, and there 
may be dyspnoea, especially toward the close of life ; 
coughing and sneezing become impossible. 

Life may be cut short by disease of the lungs, ex- 
cited by the entrance of food into the bronchi, or by 
suffocation during an attack of dyspnoea, or more slow- 
ly by starvation. 

The atrophy and paralysis are attended with changes 
of electrical reaction in the affected muscles, such as are 
found in progressive muscular atrophy. The faradic 
reaction may seem to have suffered little, as many mus- 
cular fibers remain without atrophy, though at a late 
stage it will be diminished ; but the galvanic current 
will show the reaction of degeneration when the disease 
has advanced somewhat. 

Not only the tongue, but the other affected muscles, 



BULBAR PARALYSIS. 219 

may be the seat of fine fibrillary tremors, such as are 
seen in progressive muscular atrophy. 

Nattjke or the Disease. — The nature of the atro- 
phy and paralysis in bulbar paralysis, and its relation 
or connection with progressive muscular atrophy, has 
been the subject of controversy. In both diseases there 
is the same combination of symptoms, making allow- 
ance, of course, for the difference of function in the 
different muscles. There is diminished skill or facility 
in the execution of movements, a slight paralysis, which 
gradually increases in degree ; at length atrophy is no- 
ticed, but not until so much of the muscular structure 
has degenerated as to cause the loss of function to be 
prominent ; fibrillary tremor ; change of electrical re- 
action when so much of the muscle is affected that the 
change can be recognized; the disease progresses to 
finally almost entire and absolute paralysis ; in both, 
sensation is very rarely disturbed ; the destruction of 
the large motor cells in the nuclei of the cranial nerves 
and the anterior cornua in the cord is the same in na- 
ture, so far as our means of examination enable us to 
judge. 

Besides these points of correspondence, the two dis- 
eases run into each other. Before bulbar paralysis 
ends in death, it is usual to see the limbs affected with 
muscular atrophy ; and often, in progressive muscular 
atrophy, bulbar symptoms apj)ear near the close of 
life. 

The two affections may, then, be justly looked upon 
as pathologically one disease, as clinically distinct only 
because of the wide difference in the function of the 
parts innervated by the regions affected in the cord and 
medulla. 

In very many cases, at the autopsy it has been found 
that the pyramidal tracts in the lateral and even in the 
anterior columns were altered. In some of these cases 
the exaggerated reflexes of lateral sclerosis were recog- 
nized during life. It is as yet doubtful whether this is 



220 DISEASES OF THE SPINAL CORD. 

to be considered as a secondary degeneration and com- 
plication, or whether the few cases of this character 
are to be classed as amyotrophic lateral sclerosis. 

Diagnosis. — Especially in the early stage it will re- 
quire a careful examination of all the symptoms to 
recognize the disease ; similar symptoms may be seen 
in the early stages of general paralysis ; then the vari- 
ation in pupils, the general weakness of the limbs, the 
tremor, and the mental condition of the patient, may aid 
in diagnosis, but sometimes it will be necessary to wait 
for further developments. When the disease is well 
advanced it can hardly be mistaken, yet, if a patient is 
seen in an advanced stage, without having a knowledge 
of the history of the origin and progress of the symp- 
toms, it may be very difficult to decide whether it is 
the chronic or acute bulbar paralysis. 

Prognosis. — There is no case on record of recovery 
in uncomplicated, primary bulbar paralysis. All the 
instances of recovery, if carefully examined, will be 
seen to have presented bulbar symptoms as secondary 
only. The prognosis is, therefore, unfavorable. 

When the significance of the peculiar early symp- 
toms is generally recognized in the profession, so that 
treatment can be commenced early, a more favorable 
result may be obtained. 

Eemissions of longer or shorter duration are not un- 
common, as in all chronic and slowly progressive dis- 
eases. The duration of the disease is only a few years ; 
Erb says from one to five. 

Treatment. — It is certainly rather discouraging to 
consider that no treatment has as yet been successful. 
Electricity is the most promising, and may, for a short 
time at least, contribute to the comfort of the patient ; 
it may render swallowing less difficult. The galvanic 
current should be used. It may be passed from one 
mastoid to the other, keeping the electrodes in one 
place ; Erb also recommends galvanization of the cervi- 
cal sympathetic (anode on the back of the neck, cathode 



BULBAR PARALYSIS. 221 

at the angle of the lower jaw). The electrodes may be 
applied to the sides of the neck so as to excite the mus- 
cles of deglutition, and to stimulate the recurrent laryn- 
geal nerve, using the faradic and galvanic current alter- 
nately. As the muscles are weak, having undergone 
partial atrophy, they are easily tired, therefore the ap- 
plication should be short — three to five minutes ; this 
may be repeated daily, or every other day. The treat- 
ment by electricity should be persevered with for sev- 
eral months. 

Counter-irritation, by means of dry cups, blisters, 
or cautery, has been recommended ; also hydrotherapy 
is advised. All these means may be employed, at least 
with the advantage of making the patient more con- 
tented. 

Erb says that medicines taken internally have never 
produced the very faintest effect. Still, he recommends 
the trial of nitrate of silver, iodide of potassium, iodide 
of iron, chloride of gold and sodium, ergotin, bella- 
donna, etc. 

The most important part of treatment is the general 
care of the patient. The general health is to be cared 
for by regulating the habits ; too prolonged exercise 
fatigues and exhausts, therefore injures the patient, 
especially after the muscles of the limbs are affected. 
If efforts to converse are continued too long, they ex- 
haust the muscles of the throat. The food should be 
soft, so as to require very little mastication, and be- 
cause soft solids are most readily swallowed. The pa- 
tient should be fed slowly, time enough being allowed 
for the partially atrophied muscles to rest. It may be 
well to increase the number of meals during the day. 
Finally, it may be necessary to feed the patient through 
a tube introduced into the stomach. 

When dyspnoea, or, as patients sometimes describe 
it, "attacks of asthma," occur, sedatives, narcotics, and 
stimulants, internally or by inhalation, or subcutane- 
ously, must be used. 



222 DISEASES OF THE SPINAL CORD. 



ACUTE BULBAR PARALYSIS. 

Many cases have been reported in which the symp- 
toms of bulbar paralysis have appeared suddenly, 
without the progressive character. Such cases may be 
considered as acute, and may be so called if we keep 
in mind that they are due to pathological changes quite 
different from those found in the progressive disease. 

iEiTOLOGY. — The causes of the combination of 
symptoms in these acute cases are: softening due to 
plugging of vessels by a thrombus or an embolus ; 
haemorrhage ; acute inflammation ; tumors ; and, in a 
few cases, cerebral lesions. The causes of the acute 
form would then be those that would give rise to the 
above pathological conditions. 

Symptoms. — The symptoms vary considerably from 
those found in the chronic cases. The onset of the dis- 
ease is sudden, the paralysis reaching its height in a 
few hours, or at most a few days. Convulsions of an 
epileptiform character may be among the earlier symp- 
toms. After the first attack there may be a slight im- 
provement or a remission, and afterward a steady pro- 
gression in the disease. 

Besides the bulbar symptoms due to lesion of the 
nerves of the medulla or their nuclei, there will proba- 
bly be also a rapidly occurring paralysis of the limbs, 
and sensation may be affected, as it is not in the chron- 
ic form. The paralytic symptoms may extend so as to 
show that parts anterior to the bulb are affected ; also 
the paralysis of the limbs may be unilateral and alter- 
nate — i. e., on the side opposite to that on which the 
cranial nerves are affected. In cases of acute inflam- 
mation of the medulla, such as has been reported by 
Leyden, the symptoms appear less suddenly than in 
hemorrhage or in occlusion of vessels, but they are 
developed in a comparatively short time, and other 
than bulbar symptoms appearing with them will aid in 
forming a correct diagnosis. 



ACUTE BULBAR PARALYSIS. 223 

Several times clearly marked bulbar phenomena 
have been seen where the lesion was entirely cerebral ; 
this has been noticed where the lesion has been multi- 
ple, affecting both sides of the brain : but bulbar symp- 
toms have also been found where the cerebral lesion 
has been unilateral. 

The diagnosis of the nature of the process giving 
rise to acute bulbar paralysis must be made from a 
consideration of the circumstances attending the at- 
tack : on the same principles as will aid in forming a 
diagnosis in other cases of cerebral lesion. These need 
not be reviewed here. 

The prognosis of acute bulbar paralysis is not so se- 
rious as of the progressive. Eisenlohr has reported re- 
coveries in several cases. Strimipell reports a case of 
recovery. Erb reports favorable results in a case of 
seven months' duration. 

The insidious, unpretending, progressive disease, 
which seems so much milder, and at first insignificant, 
is much the more dangerous and fatal. 

The treatment must depend upon the nature of the 
pathological process. Iodide of potassium is indicated 
if there is reason to suspect an occlusion of arteries, 
especially if there has been syphilis ; also if there is 
possibly a syphilitic thickening of the membranes. 
Erb passed a current from eight cells through the head 
from one mastoid process to the other ; and also galvan- 
ized the cervical sympathetic. 



CHAPTER XIX. 

LOCOMOTOR ATAXIA. 

TABES DORSALIS.— POSTERIOR SPINAL SCLEROSIS. 

Trousseau, A., Clinique medicale de THotel-Dieu de Paris, t. ii. 
— Eisenmann, Die Bewegungs-Ataxie. Wien, 1863. — Buzzard, 
T., On Articular and Osseous Lesions in Locomotor Ataxia. Med. 
Times and Gaz., Feb. 14, 1880 ; Brit. Med. Jour., March 5, 1881. 
— Williams, J. A., Remarks upon the Osseous Lesions of Loco- 
motor Ataxia. Lancet, Dec. 9, 1882, p. 977. — Fere, Ch., Descrip- 
tion de quelques pieces relatives aux lesions osseuses et articulaires 
des ataxiques. Arch, de neurol., iv, 1882, p. 202. — Lecoq, Etudes 
sur les accidents apoplectiformes qui peuvent compliques le debut, 
le cours, la fin de Tataxie. Rev. de med., No. 6, 1882. — Gee, Lo- 
comotor Ataxia associated with Perforating Ulcer of the Foot. 
St. Barthol. Hosp. Rep., xviii, 1882. — Friedreich, N., Ueber 
Ataxie mit besonderer Beriicksichtigung der hereditaren Formen. 
Virch. Arch., Bd. 26, 27, 68, 70.— Johnston, Nerve-Stretching. 
Brit. Med. Jour., July 2, 1881.— Bastian. lb *'<2.— Spencer. Ibid., 
Jan. 28, 1882.— Lamont. Lancet, Jan. 6, 1883.— Seguin, E. C, On 
the Early Diagnosis of some Organic Diseases of the Nervous Sys- 
tem. Med. Record, Feb. 26, 1881, p. 225.— Voigt, Syphilis with 
Ataxia. Berl. kl. Wochenschr., 1881. — Erb. CM, f. Nervenhk., 
Psych., etc., Aug. 15, 18S1.— Reumont. Ibid., Sept. 1, 1881.— 
Gowers. Lancet, Jan. 15, 1881.— Abadie. Gaz. Hebd., Dec. 1, 
1882. — Buzzard. Lancet, June 10, 1882.— Weber, Leonard. 
Med. News, March 29, 1884.— Seguin, E. C. Arch, of Med,, 
Aug., 1884. 

Pathological Ax atomy.— In the fresh state, to 
the naked eye, the posterior columns will be seen to 
have a semi-translucent appearance. This change may- 
affect the whole of the posterior columns, where the 
disease has been long present, generally in the lumbar 
region ; where the lesion is recent, only the external 



LOCOMOTOR ATAXIA. 225 

radical columns, the posterior root-zones, are affected ; 
and in its earliest periods the change of structure is 
found near the posterior cornua, not quite touching 
them and not quite reaching the periphery of the cord. 
This change of color in rare cases extends to the direct 
cerebellar tracts. 

The disease is commonly most extensive in the lum- 
bar enlargement, where it usually begins ; sometimes 
the cervical enlargement is first attacked. At whatever 
level the disease is found, it is situated in the posterior 
root-zones, or in corresponding parts in the medulla. 
Above the medulla the locality of the lesion has not 
been made out. The central parts of the posterior col- 
umns — columns of G-oll— are affected secondarily. 

The pia mater covering the part of the cord affected 
may be thickened and somewhat adherent. 

After hardening in some chromic solution, the dis- 
eased parts acquire a yellowish color, distinct from the 
darker color of the healthy parts. 

Under the microscope it will be found that the nerve- 
fibers have undergone change ; they have lost their med- 
ullary sheaths, and are reduced to their axis cylinders. 
Sometimes the axis cylinders are slightly hypertro- 
phied. The neuroglia has increased. This gives the 
cord its translucent appearaAce. When a section is 
stained by carmine, the diseased part is more intensely 
colored. 

The nerve-fibers are not all destroyed in any area, 
except in a very advanced stage of the disease, and 
groups of nearly healthy fibers, or single ones, are 
found scattered irregularly through the altered por- 
tions. 

Corpora amylacea are seen thickly scattered through 
the affected regions. 

Granular corpuscles may be rather numerous in 
early stages of the disease, but are less in number in 
the more advanced stages. 

The walls of the vessels are thickened. 

15 



226 DISEASES OF THE SPIRAL CORD. 

The nerve-cells of the anterior cornua are degener- 
ated in those cases where muscular atrophy occurs ; 
they have also been found affected in several cases of 
articular and osseous lesions. 

iETiOLOGY. — By far the larger number of patients 
are men, comparatively few being women ; children are 
only rarely affected. The age at which the first symp- 
toms are generally noticed is between twenty-five and 
forty-five years. Heredity is thought by some to act 
as a predisposing cause ; excess in the use of alcoholic 
liquors, and acute diseases, are also predisposing 
causes. 

Exposure to cold, especially to cold combined with 
wet, is one of the most frequent exciting causes. Over- 
exertion, excessive labor, especially on the feet, are 
other frequent causes of the disease ; hence, the larger 
number of patients are to be found among those whose 
occupation requires them to stand or walk nearly all 
the time, whose feet are much exposed to cold and wet. 

Lately the connection of syphilis with locomotor 
ataxia has attracted much attention. A very large pro- 
portion of ataxics are found to have had syphilis in 
early life, more than half of these to have had second- 
ary symptoms ; very many have never had these. Erb 
assigns much importance to this relation between the 
two diseases. Gowers seems to count syphilis as a pre- 
disposing cause. " It seems," he says, " that one effect 
of constitutional syphilis may be to induce a neuro- 
pathic state in which certain degenerative diseases of 
the nervous system readily occur." The proportion 
of ataxics who have had syphilis seems to be less in 
America than in Europe. 

Whatever connection there may be, or if there is 
none, it is an interesting fact that from forty-five per 
cent to eighty-eight per cent of ataxics are found to 
have had syphilis. 

Venereal excesses are generally considered as one of 
the causes of locomotor ataxia. Many times such ex- 



LOCOMOTOR ATAXIA. 22V 

cesses must be reckoned among the early symptoms of 
the disease. 

Injuries, as jar or concussion of the spine, have 
sometimes seemed to be the cause of ataxia. Cases in 
which such a relation can be traced are, however, rare. 

Symptoms. — The earliest and most extensive changes 
in the cord are found in those regions which are act- 
ive in transmitting sensation ; the earliest symptoms 
of the disease are perverted sensations ; and, as the 
changes are found throughout the whole length of the 
cerebro-spinal axis, commencing at any level, it may 
be expected that the symptoms would show a great va- 
riety both in the beginning and during the course of 
the disease. This is the case. 

The earliest symptom is pain, which is thought to 
be rheumatic or neuralgic, and no inquiry made as to its 
nature or cause. In most cases the pain is in the legs 
or feet. If the upper part of the cord is first affected, 
it may be first felt in the arms, or may follow the course 
of the occipital nerve over the back of the head ; once 
in a while the fifth nerve is affected, and the pain is 
felt in the face. The pain is peculiar in character ; it 
is of a stabbing, cutting nature, deep-seated rather 
than superficial, as if in the muscles or bones ; each 
stab is of only momentary duration, and is no sooner 
felt than it is gone ; these darts of pain succeed one 
another in rapid succession, or may be separated by a 
short interval. 

The attacks may continue several minutes or hours, 
commencing without warning, and as suddenly ceasing. 
At first they are not of frequent occurrence, but as 
time goes on they recur at shorter intervals. Some- 
times an aching or tired sensation is noticed between 
the throbs of pain, which gives the attack a resem- 
blance to rheumatism ; but the severe pain is quite dif- 
ferent from a rheumatic pain : it occurs entirely inde- 
pendent of any movement of the limbs; the aching 
between the attacks is less than is usually found in 



228 DISEASES OF THE SPINAL COED. 

rheumatism with equally severe pain ; the part affected 
is neither red nor swollen; the joints do not so fre- 
quently suffer as other parts of the limbs. The unex- 
pected occurrence of the pain, and its severity, may 
cause the sufferer to cry out and grasp the part affected. 
The terms used by patients are expressive ; they speak 
of the pain as resembling a "stroke of lightning," "a 
knife-thrust into the bone," " a red-hot iron suddenly 
buried in the flesh," though the pain does not always 
have this severity. The seat of the suffering varies ; 
the pain may be in the foot, again in the calf or thigh, 
sometimes in the right leg, again in the left, but gener- 
ally it does not give a preference for one side more than 
the other ; also in the arms and head the different at- 
tacks affect different localities, yet, as a rule, localities 
supplied by the same plexus of nerves. 

So little importance is given to the above symptom 
when first present, that medical advice is rarely sought 
until the attacks become more severe. Let the physi- 
cian be on the watch to inquire into the particulars, 
and ataxia will be oftener recognized in its earliest 
stage ; other symptoms will be found confirming the 
diagnosis. 

During the continuance of the pain, and for a short 
time after the attack has ceased, there will be a tender- 
ness of the part affected ; a very light touch will be 
painful, yet a severer irritation, as a prick with a nee- 
dle, may be scarcely felt. 

The hyperesthesia is of short duration ; anaesthesia 
is found to be more persistent, and between the attacks 
there is diminution of sensation of touch as well as of 
pain. The anaesthesia often affects the soles of the 
feet ; it may be found in circumscribed spots on the 
limbs or body, on the face or head ; its distribution is 
independent of the seat of the pain ; it is generally 
symmetrical. Localized anaesthesia is as constant a 
symptom as the pain, but is less strikingly evident to 
the patient, and may need to be searched for carefully 



LOCOMOTOR ATAXIA. 229 

by the physician. The different forms of sensation, as 
touch, pain, temperature, may be affected separately, 
and so each should be tested. 

Delay in the transmission of sensation, so that a 
touch or prick is not felt for several (three to ten or 
fifteen) seconds after contact, is less frequently an early 
symptom, but is often to be noticed later. Sometimes 
the touch is first recognized, the pain is felt later, show- 
ing a difference in the rate of transmission of the two 
varieties of sensation. 

A sense of a girdle around the body is often no- 
ticed. 

The muscular sense is not impaired till late in the 
disease. The patient can tell where his limbs are, even 
when there is much disturbance of motion ; but finally 
he loses this power. 

The special senses may be disturbed early in the dis- 
ease, even before any disturbance of general sensibility. 
Vision is affected much more frequently than hearing ; 
taste and smell are very rarely lost. 

The sight may be diminished by reason of disturb- 
ance of accommodation, by paralysis of motor muscles, 
or by limitation of the field of vision. 

The field of vision is limited because of atrophy of 
the optic nerve. The limitation, often unilateral at first, 
soon affects both eyes ; it begins on the temporal side, 
and advances so that the center of the field of vision 
remains longest unaffected. The ophthalmoscope will 
show the disk with the characteristic appearance of 
atrophy. If the change is recent, it may be possible to 
exclude a preceding neuritis ; if old, the neuritis can 
not be excluded with so much certainty. The atrophy 
and consequent limitation of vision are permanent. 

The field of vision for colors may be limited when 
perception of form is still nearly or quite perfect. This 
is a condition which has not been very carefully studied 
as yet. 

The atrophy of the optic nerve, and consequent 



230 DISEASES OF TEE SPIXAL CORD. 

limitation or loss of vision, may be the only symptom 
present for several years. If with this there is absence 
of patella tendon reflex, the diagnosis of ataxia may be 
made with a fair degree of certainty. 

It may be as well to mention here the motor dis- 
turbances of the eyes, as they also interfere with vision. 
The pupils may be extremely contracted ; they may be 
less contracted or even dilated, and not respond to vari- 
ations in the amount of light, while they will respond 
to accommodation. This has been called the "Argyll- 
Robertson symptom," from its first observer. Buzzard 
suggests that slight changes in the iris can be best seen 
by casting a strong light upon the eye with the ophthal- 
moscopic mirror, and watching the motions through, a 
convex lens of about -f 8 or + 10 placed behind it. 

Presbyopia is one of the earlier ocular symptoms. 
The change is not gradual, as when the consequence of 
advancing years, but, when symptomatic of tabes, occurs 
suddenly, perhaps in one eye only ; after a short time 
this symptom may disappear. 

Diplopia from partial paralysis of some of the ex- 
ternal ocular muscles is another form of defective 
vision ; there may also be partial ptosis of one or both 
eyelids. Rarely nearly all the ocular muscles may be 
affected. The paralysis of these muscles may pass away 
and the patient may almost forget its occurrence when 
he applies for relief from the later symptoms of ataxia. 

The hearing may suffer early— one ear may be af- 
fected or both ears may be dull of hearing. In one pa- 
tient, where the hearing was practically entirely lost, 
partial deafness occurred suddenly, then gradually in- 
creased in degree rather rapidly. 

Tinnitus aurium is mentioned as a symptom, but is 
so common under varying circumstances that it would 
be difficult to prove more than a coincidence. 

Visceral disturbances, gastric, nephritic, laryngeal, 
and bronchial crises are phenomena of disturbed sensa- 
tion occasionally met in ataxia. 



LOCOMOTOR ATAXIA. 231 

The disturbance called "gastric crises" is the most 
important of these visceral symptoms. This may be 
the dominant symptom for years, and so absorb the 
attention of both patient and physician that other phe- 
nomena are overlooked ; the patient is thought to have 
gastric ulcer, nervous dyspepsia, chronic catarrh of the 
stomach, etc. A close questioning will bring to light 
"rheumatic pains" in the limbs, an examination may 
show pupillary phenomena, and tendon reflex will be 
found absent. The diagnosis can not then be doubtful. 

These gastric crises are irregularly periodical, recur 
without certain cause, and without warning. The pa- 
tient is seized with severe pain in the epigastrium, as if 
his bowels were being tied up or twisted around ; this 
continues for a variable time, and then vomiting sets in, 
at first of ingesta, then of a glairy mucus similar to that 
ejected in catarrh or ulcer of the stomach. The amount 
of vomitus may be very great, enormous, and the pa- 
tient is surprised at the quantity. With the vomiting 
there is usually a short period of relief, only a slight 
soreness remaining. Soon the same scene is repeated. 
These attacks recur at short, sometimes long, intervals, 
for a few days or some weeks, and then cease for weeks 
or months. 

During the attack the pulse is commonly greatly in- 
creased in frequency ; but the temperature is not ele- 
vated. Sometimes during the vomiting the severe shoot- 
ing pains in the limbs are felt in their greatest intensity, 
adding materially to the patient's misery. 

Between the attacks the appetite and digestion are 
good ; the former may be ravenous. 

Nephritic crises have been described by Raynaud, 
characterized by attacks resembling renal colic with re- 
traction of testicles, anuria or ischuria, vesical tenes- 
mus, the attacks continuing six or eight days, recur- 
ring frequently, separated by intervals of health. There 
is no blood, nor pus, nor gravel found in the urine. 
These are much less common than gastric crises. 



232 DISEASES OF THE SPINAL COED. 

Laryngeal crises, where there are obstinate and 
causeless paroxysms of coughing, ending, perhaps, in 
spasm of the glottis, are even less common. Charcot 
and Vulpian have recorded cases of laryngeal crises in 
which epileptiform convulsions occurred immediately 
after the spasm of the glottis. 

The bronchial crises, where there is great dyspnoea, 
sense of constriction across the chest, as if suffocation 
were impending, are also very rare. 

The absence of patella tendon reflex (Westphal's 
symptom, as it has sometimes been called) is very con- 
stant in locomotor ataxia. In order that this phenome- 
non may be of value, it is necessary that during the ex- 
amination the knee should be bare, the leg should hang 
free, and there should be no semi- voluntary contraction 
of muscles. In doubtful cases it is well to have the pa- 
tient shut his eyes and to strike one knee or the other 
without giving him warning as to where the blow is to 
fall. The absence of patella tendon reflex may be found 
in other diseases, but in locomotor ataxia it is associ- 
ated with considerable voluntary muscular power, and 
when the vastus internus is smartly filliped, it is seen 
to contract. Buzzard and Erb both insist upon the 
need of these conditions as aids in judging of the sig- 
nificance of the phenomenon. 

Occasionally patella tendon reflex is present in an 
undoubted case of locomotor ataxia, and I have seen 
cases where it reappeared after having been absent. It 
is absent in about 1 - 5 per cent of healthy persons. 

This is usually an early symptom, and by some au- 
thors it is claimed that it may be noticed before any 
other symptom. It is one of the most constant, as will 
be mentioned later. Sometimes, however, the tendon 
reflex does not disappear till after other symptoms have 
been long present. 

Cutaneous reflexes are, as a rule, retained in normal 
intensity, though when there is hyperesthesia the re- 
flex excited by irritating such a spot may be exagger- 



LOCOMOTOR ATAXIA. 233 

ated, and, when sensation is markedly delayed, cutane- 
ous reflexes may also be delayed. 

Motor disturbances do not belong to the earliest 
symptoms in locomotor ataxia. The first discomfort 
in this respect noticed by the patient is a sense of weari- 
ness ; he is more quickly tired than usual. This may 
be laid to various causes, and frequently is thought to 
be one result of the rheumatism which causes the pain. 

At a later period there is a loss of co-ordination in 
the use of the muscles. The patient is aware that he 
needs to use his eyes in order to walk reasonably 
straight ; or, before he is conscious of this, if examined, 
he will be found to have lost the control of his limbs, 
and he can not walk straight with his eyes shut. If in 
bed, with feet wide apart, he is told to shut his eyes, 
raise one foot, and slowly carry it across the bed and 
bring it down by the side of its fellow, the foot is 
moved irregularly with a jerking motion and is not 
placed correctly in the place mentioned. 

The inco-ordination may affect the arms before the 
legs, or after. Then the patient has difficulty in feed- 
ing himself or in writing or performing other acts re- 
quiring delicate manipulation. If, with eyes shut, he 
is told to touch the end of his nose with his forefinger, 
the finger will go wide of the mark. 

The gait of an ataxic is peculiar ; he walks with his 
feet wide apart, straddling ; they come down heavily 
upon the floor, the heels striking first ; the body sways 
somewhat from side to side ; if the inco-ordination is 
great, support is needed, and then the legs move irregu- 
larly. 

Inco-ordination is not as constant a symptom as 
many others, and is much less important than was for- 
merly supposed. 

With the loss of complete control over the limbs, 
and perhaps an inability to walk, there is comparatively 
little loss of muscular strength ; while lying in bed, the 
patient can move freely, and resist passive flexion or 



234 DISEASES OF THE SPWAL CORD. 

extension of the limbs with great power. Not until 
the closing period of the disease is there decided pa- 
ralysis, except that occasionally a paralysis, which soon 
disappears, may follow a severe attack of pain. 

Sexual desire is sometimes exaggerated, and hence 
venereal excess may be one of the symptoms rather 
than one of the causes ; but it is probably rather an 
early symptom of the disease. Frequent emissions are 
also met. Sometimes sexual desire is greatly increased, 
but there is entire loss of power to gratify the desire, 
and, while suffering from it, there is not the slightest 
trace of erection. This impotence is not one of the 
earliest symptoms, though it may be noticed by the 
patient before he has given much thought to the other 
earlier symptoms. 

The bladder may be affected ; rarely there is pain 
with dysuria, and frequent calls to empty the viscus. 
It is more common to have difficulty in voiding the 
urine from partial paralysis or anaesthesia, and finally 
the retention may lead to cystitis. 

The bowels are usually unaffected, except a slight 
constipation ; but this may give some trouble. Rarely 
there are attacks of looseness. When there is great 
anaesthesia, the faeces may pass without the patient's 
knowledge. 

Trophic changes are not uncommon ; among these 
the affection of the joints is most striking and charac- 
teristic. The limb swells from effusion into the joint, 
which may be very great, and a large part of the limb 
may be enlarged ; there is oftentimes some redness and 
slight pain, but these are only moderate. Within a 
very short time it will be found that the articular sur- 
faces forming the joint have suffered loss of substance, 
and, when the limb is moved in certain directions, crepi- 
tus will be felt. After a while the serous effusion is 
absorbed, and the erosion of the articular surfaces con- 
tinues if the joint is still used. The surface of the 
bones is roughened, and their chemical composition 



LOCOMOTOR ATAXIA. 235 

altered ; the earthy salts are absorbed, and a great ex- 
cess of fat is deposited. 

The larger joints are most commonly affected — the 
knee and hip, the elbow and shoulder ; but the jaws and 
smaller joints may be attacked. The chief characteris- 
tics of this change are the sndden and rapid effusion 
into the joint, without fever, and with but little pain, 
if any ; the early erosion of the articular surfaces, also 
without pain. 

The changes in the joints give rise to dislocations, 
and the bones assume abnormal positions ; the destruc- 
tion of ligaments or their elongation allows the limbs 
to be hyperextended. 

Occasionally osseous growths form in the vicinity of 
joints in the soft parts, as if an effort were made to 
compensate for the injury by the formation of osseous 
splints or supports. Sometimes the ends of the bones 
are not eroded, but undergo hypertrophy. 

The change in the composition of bones, which fa- 
cilitates erosion of articular surfaces, renders them also 
liable to fracture ; and this accident easily happens, not 
only to the long bones, but to those of the pelvis as 
well, sometimes from simple muscular action. The 
callus thrown out in such cases is usually very large, 
and lacks in solidity. 

These osseous lesions are not among the earliest 
symptoms, but they sometimes are the first to attract 
notice. Charcot places them between the pains and 
the inco-ordination, though sometimes they appear 
later. 

In a few instances muscular atrophy has been seen 
in cases of locomotor ataxia ; when an autopsy has been 
obtained in such cases, it has been found that the cells 
of the anterior cornua were secondarily affected. 

Less frequent than the osseous lesions we find tro- 
phic changes in the skin, erythema, herpes, bullae, pus- 
tular eruptions, ulcerations, as mal perforant. These 
changes may appear and disappear frequently, and are 



236 DISEASES OF THE SPIRAL CORD. 

found over the region supplied from the plexus, whence 
arises the nerve in which pain is felt, though the erup- 
tion may not occur in the tract of that nerve. They are 
most frequently met during the continuance of pain. 

Serious mental disturbance is rare except in those 
cases associated with general paralysis. The symp- 
toms of ataxia may arise before those of general pa- 
ralysis appear, or the latter may be primary, and the 
spinal affection set in later. 

Sometimes the patient becomes irritable or melan- 
cholic, but generally is in good spirits, and very pa- 
tient. A very few instances of suicide have occurred 
in patients who dreaded a long and helpless illness. 

Among rarer symptoms or complications may be 
mentioned apoplectic attacks with hemiplegia (Lecoq) 
and aphasia, usually not permanent. 

A form of spinal or cerebro-spinal disease, which is 
probably a sclerosis, has been described by Friedreich, 
Carre, Eiitimeyer, and others, under the title of heredi- 
tary ataxia. It attacks several members of a family, 
sometimes appearing at the age of four years, some- 
times as late as the eighteenth year. 

There is not the lancinating pain, the ataxic gait 
appears early, and soon there is inco-ordination of the 
upper extremities; the speech shows disturbance of 
co-ordination, and there is ataxic nystagmus ; tendon 
reflex is absent ; there is often a slight diminution of 
sensibility ; muscular sense is not disturbed ; at length 
there is paraplegia with contracture ; bed-sores rarely 
form ; there is no disturbance of the bladder ; the mind 
is not affected. 

Rutimeyer thinks the lesion affects the spinal cord 
primarily ; the medulla oblongata and corpora quadri- 
gemina secondarily. It is certainly not simple locomo- 
tor ataxia. 

Bernhardt, Erb, and Yoigt have given the percent- 
age of cases in which the different symptoms occur in 
locomotor ataxia. 



LOCOMOTOR ATAXIA. 



237 



The following table gives the percentages according 
to these three observers. The nnmber of cases of each 
was under sixty ; the agreement between the three is 
noteworthy : 



Tendon reflex absent 

Ataxia 

Staggering, with eyes shut 

Staggering, non-ataxic 

Sense of tiredness 

Loss of power in walking 

Loss of strength 

Upper extremities affected 

Sensory disturbance 

Diminished sense of touch 

Diminished sense of place 

Diminished sense of temperature 
Diminished sense of pressure. . . . 

Diminished sense of pain 

Delayed sensation 

Painful after impressions 

Paresthesia 

Girdle sensation 

Lancinating pains 

Diminished muscular sense 

Bladder symptoms 

Constipation 

Impotence 

Gastric crises 

Immobile pupil 

Myosis 

Paralysis of ocular muscles 

Diplopia.. 

Optic atrophy 



Voigt. 



Per cent. 

96-5 



93 

95 ' 
59-5 
19 

98 ' 

94-5 

35 

45-5 

68 

72 

41 

89-5 

78-5 

94-5 



51 
82 
8-5 
63 
45-5 
28 

17-5 



Per cent. 
95-6 
94-1 



92 



85- 



31-6 
34-37 



79-5 

76-07 

43-7 

48-4 

27-2 

39-6 
10-3 



'er cent. 

98 
100 
93-5 



92-5 
81 



54 
38-7 

12-3 



A resume of the clinical history may group these 
symptoms together more connectedly. 

The earliest symptoms are apt to be mistaken or 
neglected ; they are a temporary diplopia or blurring 
of vision from presbyopia, which soon passes ; occa- 
sional attacks of pain in different parts of the body, 
these sometimes very severe, but of momentary dura- 
tion; these attacks, thought to be rheumatic, recur 
with increasing frequency ; hyperesthesia during the 



238 DISEASES OF THE SPINAL CORD. 

attacks and just after ; circumscribed anaesthesia, often 
symmetrical ; more serious loss of vision from atrophy 
of optic nerve ; pupillary phenomena, Argyll- Robertson 
symptom ; occasionally deafness or tinnitus, unilat- 
eral or bilateral ; weariness and rapidly occurring tired 
sensation on exercising ; absence of patella tendon re- 
flex ; various trophic changes ; ataxic gait and inco-or- 
dination with at most only fugitive paralysis, and rarely 
even that. Such are the earlier symptoms, and those 
of the fully developed disease. 

As time elapses, the sensory and motor disturbances 
increase in gravity ; the ataxic phenomena become more 
and more marked, until walking and even standing is 
impossible ; sensation is finally entirely lost ; the arms 
as well as the legs are affected ; the patient is helpless. 
If to this blindness and deafness are added, his condi- 
tion is jritiable ; fortunately, this is rare. Death may 
result from some intercurrent disease, or from exhaus- 
tion. 

The disease is of long duration. The earlier stage, 
during which the patient can keep about, suffering only 
during the attacks of pain, may continue for ten to 
twenty years. There are frequent periods of remission, 
or even apparent cure. The average duration of typi- 
cal cases is eight or ten years. 

Diagnosis. — When the history of a case is fully 
known, the early occurrence of lancinating j>ain in the 
legs or elsewhere, with a sense of tiredness, occurring 
soon after exertion ; the pupillary and ocular phenome- 
na ; the absence of tendon reflex ; the anaesthesia ; and 
the ataxic disturbance of motion, occurring at a some- 
what later period — are sufficient for diagnosis. At a 
late period of the disease, if the history is not known, 
the diagnosis might be less clear. 

There may be anaesthesia and a resemblance to in- 
co-ordination arising from weakness in myelitis ; but in 
this case there will probably be little or no pain, and 
the weakness would show itself when the patient is 



LOCOMOTOR ATAXIA. 239 

lying down. If the myelitis were at all acute, the du- 
ration would probably have been short, with some 
febrile action. Spinal meningitis is not likely to be mis- 
taken for ataxia. 

In disease of the cerebellum there may be lack of 
co-ordination, with retention of muscular strength ; but 
the disturbance of co-ordination is rather different from 
that seen in ataxia. In walking, the patient has not 
the same gait, and there are head symptoms which are 
not found in ataxia. 

Cerebro-spinal sclerosis generally differs from ataxia 
in that there is more muscular weakness, tremor on 
performing voluntary acts, disturbance of speech, little 
or no disturbance of sensation, and ataxic inco-ordina- 
tion is rare. There are cases, however, where the dis- 
ease has extended to the posterior columns, which it is 
almost or quite impossible to diagnosticate from loco- 
motor ataxia, especially if tremor is absent, as occa- 
sionally happens. 

Pkogjstosis. — In advanced cases recovery can not be 
expected ; there may be pauses in the progress of the 
disease, or the patient may grow worse so very slowly 
that both he and his friends are encouraged in the hope 
of his recovery, but such hopes are almost invariably 
delusive. Seasons of apparent improvement, in which 
the pains cease and the ataxia diminishes, are not rare 
in the earlier stages of the disease. It is not unlikely 
that reported cures are cases where such improvement 
has occurred. If the disease is not too far advanced, 
its progress may be checked by treatment ; individual 
symptoms can almost always be ameliorated. The du- 
ration is always long, extending over many years, and 
the knowledge of this fact is often a source of comfort 
to the patient and his friends. 

When the disease seems to be of short duration, yet 
to have advanced rapidly — cases which seem to run an 
acute course— the prognosis is less unfavorable, though 
in such cases the diagnosis is not sure. Lesion of pe- 



240 DISEASES OF THE SPINAL CORD. 

riplieral nerves may give rise to the symptoms observed 
under these circumstances. 

Teeatment. — If possible, patients should be re- 
stricted in regard to exercise, especially walking, and 
forbidden to over-exert themselves so as to cause a 
sense of exhaustion. They should also avoid getting 
their feet wet, and exposure to draughts of cold air 
about the feet and legs. The extremities should be 
warmly clothed. Mental over-exertion, excessive care 
and worry, are only a little less injurious than physical 
exertion. Much indulgence in coitus should be abso- 
lutely forbidden. Benefit is found sometimes from 
confining the patient to bed during several weeks, 
every exertion and motion being forbidden, the patient 
not being allowed to rise for any purpose whatever. 
This can be endured by the patient only when accom- 
panied with daily frictions and massage. 

Of drugs, nitrate of silver, in doses of one quarter to 
one half a grain three times daily, is of great benefit 
in many cases ; many times this relieves the pain and 
increases the feeling of strength. Double chloride of 
gold and sodium is also recommended. Ergot has been 
much used and commended. Iodide of potassium, is 
sometimes followed by benefit. The galvanic current is 
well deserving of trial, and frequently seems to be of 
benefit ; it should be applied to the back, one pole 
being placed in the cervical region, either in the 
center of the back or on the side of the neck, the 
other pole being passed slowly over the dorsal and 
lumbar region. The duration of the application should 
not exceed from five to eight minutes ; a compara- 
tively weak current should be used, not so strong 
as to produce any discomfort. The actual cautery, 
passed very rapidly over the spine, may be of great 
service. 

In Europe, hydrotherapy is much commended. Cold 
baths are not to be recommended ; cool baths, with a 
temperature of from 70° to 80°, especially sponge-baths, 



LOCOMOTOR ATAXIA. 241 

may often be used with advantage. Hot baths are to 
be avoided. 

The pains in the legs frequently require special 
treatment. Sometimes external applications, as lini- 
ments, especially irritating liniments, will give relief. 
A lotion composed of chloroform and alcohol, in vary- 
ing proportion, with a small amount of tincture of 
aconite-root, will often give relief ; this should be put 
on a piece of flannel wrapped around the limb, and cov- 
ered with a towel wet in water, to prevent evaporation. 
Sulphide of carbon may be used in the same way. 
Iodide of potassium internally is said to sometimes 
give relief. The actual cautery to the back may be 
used to relieve the pain in the legs. The galvanic cur- 
rent may be applied to the limb. If it is possible to 
relieve the pain without having resort to morphia, it is 
desirable to do so, especially in view of the long dura- 
tion of the disease ; sometimes, however, it is neces- 
sary to use that drug, and its effect is prompt. The 
frequent use of morphia endangers the development of 
the opium habit. 

Lately nerve-stretching has been tried ; many cases 
have seemed to be temporarily benefited, but it is rarely 
that any permanent benefit has been obtained. The 
lancinating pains have been more relieved than other 
symptoms by this operation, which deserves further 
trial. 

16 



CHAPTER XX. 

SCLEEOSIS. 

Bourneville et L. GrUERARD, De la sclerose en plaques disse- 
minees. Paris, 1869. — Moxon, W., Eight Cases of Insular Sclero- 
sis. Guy's Hosp. Reports, 1875. — Buzzard, T., On Some Points 
in the Diagnosis of Spinal Sclerosis. Lancet, July 27, 1878, p. 111. 
— Wood, H. C, Multiple Spinal Sclerosis. Med. Record, Sept. 21, 
1878, p. 224.— Althaus, Julius. Brit. Med. Jour., May 10, 17, 
24, 31, 1884.— Dickinson. Med. Times and Gaz., Feb. 2, 1878, p. 
112.— Bastian, H. C. Med. Times and Gaz., Oct. 20, 1883, p. 451. 

Charcot, Sclerose des cordons laterales. Gaz. hebd., 1865, 
No. 7 ; Arch, de physiol, 1872, p. 509. — Erb, Ueher die spastische 
Spinalparalyse. Virch. Arch., lxx, 1877, p. 241.— Dreschfeld, 
J., A Contribution to the Morbid Anatomy of the Primary Lateral 
Sclerosis. Journal of Anat. and Physiol., July, 1881, p. 510. — 
Weiss, N., Ueber spastische Spinalparalyse. Wien. med. Wochen- 
schr., Feb., 1883. — Charcot, Sclerose laterale amyotrophique. 
Gaz. des Hop., Nov. 20, 1879.— Cox well, Amyotrophic Lateral 
Sclerosis. Lancet, Feb. 23, 1884, p. 343.— Debove et Gombault. 
Arch, de physiol., Sept., 1879. 

MULTIPLE SCLEROSIS. 

Multiple sclerosis is the name given to a chronic in- 
flammation of the interstitial tissue of the spinal cord 
and brain, occurring in patches of greater or less size 
scattered irregularly throughout the white substance, 
only rarely invading the gray substance. The proper 
nervous structures are affected secondarily, undergoing 
atrophy, and finally disappear. 

Pathological Anatomy. — The pathological pro- 
cess is similar to that found in interstitial inflammation 
in other organs. The cellular elements are increased in 
number and in size ; the fibrous tissue is increased ; the 



MULTIPLE SCLEROSIS. 243 

nerve-fibers suffer in their nutrition, are secondarily- 
affected with inflammatory changes, suffer atrophy, 
lose their medullary sheaths ; the axis cylinders persist 
for an indefinite time, and finally disappear. There is 
left then a close net-work of fibers surrounding and 
inclosing nuclei and cells of the neuroglia. Granular 
corpuscles are found in the earlier stages. The cord 
acquires sometimes a firm consistency, though it may 
be softer than normal; it has a grayish, translucent 
appearance, the white substance somewhat resembling 
thus the gray substance. 

The walls of the blood-vessels are thickened, and it 
is impossible to tell how soon this change sets in. 

It is only exceptionally that the nerve-cells of the 
gray substance are altered. 

The spots of disease, varying greatly in size, may 
be situated in any portion of the central nervous sys- 
tem ; sometimes there are few in the cord and more in 
the brain, or the brain may be the less affected. They 
are found in all parts of the brain, in the crura, pons, 
and medulla, and are perhaps less frequent in the cere- 
bellum. The nerves, especially the optic and auditory 
nerves, may also be affected. 

.ZEtiology. — The cause of sclerosis can be definitely 
determined in only a few cases. It is a disease of early 
adult life, yet it is found in childhood, and even in in- 
fancy, Seeligmuller reporting a case aged one year and 
nine months ; several cases have been reported between 
four and ten years of age. It is, however, most fre- 
quent between twenty and thirty years. Charcot sets 
forty as the extreme limit when it appears. 

Heredity seems to have little or no setiological influ- 
ence, though Seeligmuller reports four cases, all under 
ten years, in one family. 

Charcot and some others following him have stated 
that the disease is more common among women than 
men. This may be so to some extent, but statistics 
are too meager to settle this point. 



2U DISEASES OF TEE SPIXAL COED. 

Accidents involving the spine, causing concussion 
or jar of the cord, may be exciting causes of the dis- 
ease. Acute diseases, typhoid fever especially, may be 
followed by cerebro-spinal sclerosis. Protracted and 
excessive toil seems sometimes to be the cause; also 
mental disturbances, as worry, anxiety, or fright. 

Symptoms. — After injuries, mental shocks, or when 
following acute diseases, cerebro-spinal sclerosis may 
develop rapidly, so that an early diagnosis is possible. 
Generally, however, the first symptoms are so insignifi- 
cant that they are not considered by the patient to be 
of importance, and so are neglected ; indeed, it is not 
possible to foretell whether the slight motor and sen- 
sory disturbances which first give warning of more seri- 
ous trouble will continue, or may not prove mere tran- 
sitory phenomena. 

The earlier symptoms are generally not continuous ; 
they are also varied in character, sometimes referable 
to cerebral disturbance, sometimes to spinal; the pa- 
tient may be thought to be hysterical, or suffering sim- 
ply from neurasthenia. 

Very frequently the first complaint is in regard to 
motor disturbance — there is weakness, and it is difficult 
for the patient to ascend or descend stairs ; he wearies 
sooner than usual in walking ; he can no longer follow 
his usual occupation with comfort ; after a while a tre- 
mor of the hand is noticed, the handwriting becomes 
less legible, and then it is impossible to write on account 
of the tremor. 

The disturbances of sensation during the earlier 
stages are not constant ; there may be distress in the 
head, and sometimes headache or dizziness ; severe pain 
anywhere is rare, though it sometimes occurs ; there 
may be backache or weariness following exertion ; 
numbness and abnormal tingling sensations in the limbs 
are not uncommon. Diplopia and ambliopia are occa- 
sionally noticed. Nystagmus is a much more frequent 
symptom. 



MULTIPLE SCLEROSIS. 245 

These earlier symptoms may be present for many 
weeks or months in such slight degree, or with such 
varying conditions of apparent good health, that no 
notice is taken of them. Finally they become so severe 
as to oblige the patient to acknowledge that he is ill ; 
it is more frequently the tremor and weakness which 
cause the most annoyance. Often there is so little sen- 
sory disturbance, that the patient does not consider 
himself seriously sick. 

The tremor is characteristic. When at rest, the 
limbs are quiet and motionless ; when a voluntary 
motion is performed, the limb trembles, at first only 
slightly ; later, the tremor is so severe as to interfere 
seriously with the use of the hands. It is seen most 
clearly when the patient tries to perform some act re- 
quiring a careful balancing of the muscular forces, as 
the carrying a cup or spoon to the mouth, or the use of 
a pen. As the disease advances, the trembling may in- 
crease until all use of the limbs is impossible, or the 
whole body may be tossed about, or the tremor may 
disappear ; then there is left great weakness, partial 
paralysis. 

The legs are affected similarly to the arms, but the 
tremor is less easily recognized in them ; yet, by asking 
the patient to execute movements with the legs while 
lying or seated, the tremor can be recognized. There 
may be stiffness and weakness which interfere with 
walking, but differing from the inco-ordination found 
in ataxia. As the disease advances, the instability and 
weakness of the legs become so great as to oblige the 
patient to give up walking. 

The nystagmus, which has been mentioned in con- 
nection with ocular affections, is clue to the tremor of 
the muscles of the eyeball. The motion is a lateral 
one ; it can sometimes be made more prominent by 
asking the patient to look to one side or at an object 
held near the eyes, so as to require an exertion of the 
will to adjust the axes of the eyes to distinct vision — 



246 DISEASES OF THE SPIRAL COED. 

that is, when the eyes are at rest there is no tremor, but 
a voluntary effort causes it. 

Allied to the other motor disturbances is a peculiar 
manner of speaking : at first there is merely a slight 
hesitation, a drawling utterance ; then there is more 
delay in pronouncing the individual syllables, and the 
sentences are, as it were, scanned. Some disturbance 
of speech is very common. 

Reflex motions are not lost, may be somewhat ex- 
aggerated, especially the patella-tendon reflex, except 
toward the close of the disease, or in the rare cases 
where the posterior columns are much affected. Ankle 
clonus may be present when the lateral columns are 
considerably diseased ; it may appear, and after a while 
disappear, according to changes in the cord during the 
progress of the disease. 

The electrical reaction of the muscles is not altered 
unless, in rare instances, the disease invades the ante- 
rior cornua, and then there is muscular atrophy. 

In the later stages, sensation may be more affected, 
and spots of anaesthesia may be found scattered over 
the limbs or body. Pain is rare even in the later stages. 
Disagreeable sensations of tingling, formication, a sen- 
sation as if the limbs were asleep, are not uncommon. 
A sinking or faint feeling may give much distress. 

Sometimes the cerebral symptoms are very promi- 
nent; headache, dizziness or vertigo, change of dispo- 
sition, mental heaviness, are among the more frequent 
cerebral symptoms. 

Pseudo-apoplectic attacks may occur; the patient 
suddenly becomes unconscious, is hemiplegic, and may 
have convulsions ; the symptoms closely resemble those 
of an ordinary attack of cerebral haemorrhage. The 
attack may end fatally, or gradually consciousness is 
regained, the motor power returns, and the patient re- 
covers, yet is usually not quite so well as before the 
attack. The course of the temperature is a valuable 
aid in diagnosis in these attacks. According to Charcot, 



MULTIPLE SCLEROSIS. 247 

the temperature rises with the commencement of the 
attack, and may reach 104° within twenty-four hours ; 
unless death occurs, the temperature falls to normal by 
the second or third day. The pulse is also rapid at the 
beginning of the attack. Several of these apoplecti- 
form attacks may occur at intervals during the course 
of the disease. 

When the interstitial changes affect the posterior col- 
umns, we may have symptoms of locomotor ataxia com- 
plicating and masking those of the original disease. 
When the lateral columns are chiefly affected, symp- 
toms corresponding with the location of the disease 
will be noticed. 

Besides cerebro-spinal multiple sclerosis, some au- 
thors recognize a cerebral form and a spinal form of the 
disease. While it is true that the brain or spinal cord 
may be chiefly affected, it is very rare that either is 
exclusively the seat of the disease. Occasionally the 
spinal symptoms predominate, all mental phenomena, 
even trembling, being absent. Such a case may resem- 
ble simple chronic myelitis, except that the symptoms 
are more general and advance more irregularly than in 
that disease. It is very doubtful whether cerebral 
sclerosis has ever been seen without lesion of the spinal 
cord. 

Diagnosis. — Multiple sclerosis was formerly con- 
founded with paralysis agitans on account of the 
tremor. If the nature of this tremor is observed, it is 
scarcely possible to make such a mistake ; in sclerosis 
the tremor ceases when the limbs are at rest, or is very 
much less marked in the few cases where it is so severe 
as to be nearly constant. In paralysis agitans the 
tremor is at least as well marked during repose, and 
usually it is much diminished during voluntary exer- 
tion. 

Ordinary cases of chorea and multiple sclerosis are 
not likely to be mistaken, except where the tremor of 
sclerosis is extremely severe and almost continuous. 



2±S DISEASES OF TEE SPINAL CORD. 

There is much similarity between the motions in such a 
case and those found in severe cases of chorea. A care- 
ful study of the history and course of the disease 
would probably prevent a mistake. 

Cerebral pachymeningitis may also resemble multi- 
ple sclerosis, but a careful study of the history of the 
case and examination of the symptoms will guard 
against error. 

When the sclerosis affects the posterior columns of 
the spinal cord, the symptoms may correspond in many 
respects with those found in locomotor ataxia. If the 
tremor is slight, or has not shown itself, and the tendon 
reflex is lost, it may not be possible to make a correct 
diagnosis. When the characteristic tremor is present, 
and the tendon reflex is retained, there should not be 
any mistake made. 

It may not always be easy to decide the diagnosis 
between sclerosis and general paralysis, especially if 
the mental symptoms are slight or entirely absent in 
the latter. In general paralysis there is tremor of the 
facial muscles and tongue during voluntary motion 
rather than of the muscles of the extremity ; the pupils 
may be unequal ; the disturbance of speech is different, 
the person talks with an indistinctness of utterance 
and a hesitation, repeating his words or sentences, 
sometimes pausing for a few seconds or a minute, then 
finishing his sentence. In sclerosis the patient is aware 
that his health is defective ; in general paralysis he 
seems to consider himself well, and does not recognize 
symptoms which are evident to others. If delusions of 
grandeur or other mental disturbances characteristic 
of general paralysis show themselves, the diagnosis, of 
course, is easy. 

Peog^osis. — When once multiple sclerosis has been 
certainly recognized, we must consider that the patient's 
fate is sealed, that he will not recover health, that the 
disease will probably steadily progress to a fatal ter- 
mination unless life is shortened by some intercurrent 



MULTIPLE SCLEROSIS. 249 

affection. The progress of the disease may, however, 
be interrupted by remissions of longer or shorter dura- 
tion ; during these the severity of the symptoms may 
diminish, and there may seem to be a flattering pros- 
pect of recovery, but the symptoms are sure to return. 

It is not possible to fix the duration of the disease 
with any degree of certainty ; from the time the nature 
of the affection is recognized to the fatal termination 
may be only twenty or thirty months, but is usually 
much longer, and, if the disease is confined chiefly to 
the spinal cord, its duration may extend to fifteen or 
twenty years. 

Treatment. — The general testimony of observers is 
that treatment is frequently of no avail. The remedies 
which have proved of temporary value are, nitrate of 
silver in doses of from £ to £ grain three times a day ; 
double chloride of gold and sodium, ■£$ grain ; ergot, 
iodide of potassium, and arsenic either by mouth or 
subcutaneously. Bathing has been recommended ; the 
baths should be neither too cold nor too hot, but cool 
rather than warm. Greater advantage may be expected 
from a persistent use of electricity ; the applications 
should be made daily or every other day with the gal- 
vanic current, not too strong, to the back, one pole above, 
the other below, over the spine ; the direction of the 
current is a matter of indifference — it may be varied at 
different sittings. A much weaker current may be 
passed transversely through the head, the poles being 
placed behind the ears ; great care must be taken not 
to use too strong a current. To obtain good results 
from electricity, it must be continued through many 
months. 

Patients should not be allowed to fatigue themselves, 
either by attending to the ordinary occupations of life, 
or by taking exercise under the impression that it will 
strengthen them ; over-fatigue of mind should also be 
avoided ; alcoholic drinks had better be forbidden, and 
tea or coffee used only in moderation. 



250 DISEASES 01 THE SPINAL CORD. 

SCLEROSIS OF THE LATERAL COLUMNS. 

This affection lias also been called spastic spinal 
paralysis and spasmodic tabes dorsalis, and, though pre- 
viously described by Tiirck, was first recognized as a 
distinct form of sclerosis by Charcot, and later by Erb. 
Though for some years there was doubt whether scle- 
rosis of the lateral columns can properly be considered 
a distinct disease, the opinion seems to be gaining 
ground that it is distinct from other lesions of the 
cord. 

Pathological Anatomy. — The pathological changes 
are such as are found in locomotor ataxia, and are 
generally confined to the lateral pyramidal tract — that 
portion of the lateral columns affected by secondary 
descending degeneration. The pathological change 
may extend somewhat beyond this region. A variety 
of lateral sclerosis, called by Charcot amyotrophic, is 
characterized by destruction of the nerve-cells in the 
anterior cornua, in addition to the changes in the lat- 
eral columns. 

The causes are obscure, and no satisfactory obser- 
vations have been made on that point. 

Symptoms. — The motor symptoms are most promi- 
nent, and may commence in the upper or lower ex- 
tremities ; rather more frequently, perhaps, in the latter. 
First is noticed a slight weakness and tendency to be- 
come easily fatigued. The weakness gradually in- 
creases until the patient has great difficulty in getting 
about, or is confined to the bed. This symptom may 
first appear in one limb only ; but after a while the 
other limb is also affected, and before death all four 
extremities are usually implicated. Ataxic symptoms 
are very seldom seen. 

Besides the above paralytic phenomena, a class of 
symptoms are developed which are peculiar to lesions 
of the pyramidal tracts. These may appear even in 
the early stages of the disease, when the weakness is 



SCLEROSIS OF THE LATERAL COLUMN'S. 251 

as yet very slight ; they consist in spasmodic jerkings 
and tremors, with other signs of irritation. 

The tendon reflex is greatly exaggerated ; a very 
slight tap just below the knee causes the leg to jerk 
forward with considerable force ; other tendons also 
show an increase of reflex irritability, as in the arms 
just above the olecranon at the elbow, over the tendon 
of the triceps, or at the wrist, and sometimes over the 
tendons of the muscles of the shoulder and neck. An- 
kle clonus is generally very strong. 

Owing to this increase of tendon reflex, the patient' s 
gait is peculiar, called by Erb the spastic gait, and thus 
described by him: "The legs are somewhat dragged, 
the feet seem to cleave to the ground, the tips of the 
feet find an obstacle in every inequality of the ground ; 
every step is accompanied by a peculiar hopping eleva- 
tion of the whole body, dependent on a reflex contrac- 
tion of the calf ; the patient immediately gets upon his 
toes and slips forward on them, showing a tendency 
to fall forward. The legs are close together, held 
stiffly, the knees somewhat depressed forward. There 
is no throwing about of the feet. This gait depends on 
muscular tension and reflex contractions in the various 
groups of muscles, which are set in activity during the 
process of walking." 

The increase of reflex irritability is shown by spon- 
taneous jerking and twitching of the limbs occurring 
when the patient is lying down, but in extreme cases 
occurring also when he is sitting. The extensor mus- 
cles are most frequently affected ; sometimes, however, 
the flexors draw the knees and legs spasmodically ; the 
spasm consists simply of a strong tremor of the limbs, 
which is often excited by the act of stretching. A 
spasmodic stiffness of the limbs, at first intermittent, 
interferes with motion ; when this stiffness becomes 
continuous, there is permanent contracture of the 
limbs, the legs and feet being extended, the toes are 
sometimes flexed ; the adductor muscles keep the legs 



252 DISEASES OF THE SPINAL CORD. 

closely approximated to each other. The arms are 
much less frequently affected with contracture. 

Erb found the skin reflexes generally normal in 
about two thirds of his cases, increased in hardly 
one third. He found the faradic and galvanic excit- 
ability of the motor nerves slightly lowered, never 
increased. 

The functions of the bladder and rectum, and the 
sexual function, are not interfered with. 

There are no brain nor bulbar symptoms. Sensa- 
tion is not disturbed when only the lateral columns are 
diseased. 

AMYOTROPHIC LATERAL SCLEROSIS. 

Gharcot first described a form of disease in which 
sclerosis of the lateral columns is associated with atro- 
phy and destruction of the cells of the anterior cornua. 
The pathological changes are the same as those in lat- 
eral sclerosis, with the addition of destruction of nerve- 
cells of the anterior cornua, those in the upper part of 
the cervical region being most affected ; one group of 
cells is not more likely to be diseased than another ; 
both sides are usually affected. The hypoglossal nu- 
cleus, and sometimes the other nerve-centers of the me- 
dulla oblongata, may be affected as well as the cells in 
the cervical region of the cord. 

The nerve-roots and trunks, which take their origin 
from the diseased cornua, suffer secondary atrophy, 
and the muscles supplied by them undergo the usual 
atrophic changes. 

The first symptom is a weakness of the hands, fol- 
lowed soon by wasting and spasmodic rigidity ; fibril- 
lary contractions are generally to be seen in the affected 
muscles. Finally, the symptoms of bulbar paralysis 
(labio-glosso-laryngeal paralysis) show themselves ; the 
tongue and lips are paralyzed, swallowing is difficult or 
impossible, and speech is very much interfered with. 
The legs rarely show marked signs of wasting ; the 



AMYOTROPHIC LATERAL SCLEROSIS. 253 

symptoms, as already described as due to lateral scle- 
rosis, are developed in the legs. 

The electrical contractility of the muscles suffers 
in so far as there is atrophy. Sensation is but little 
disturbed, though there is sometimes a painful hyper- 
sesthesia of the muscles affected. Sometimes the con- 
tractures disappear before death. 

The prognosis is decidedly unfavorable, and the 
course of the disease much more rapid than that of 
simple lateral sclerosis, the usual duration being only 
two or three years. 

Pkognosis and Diagnosis.— The progress of the 
disease is very slow, and, interrupted by periods of re- 
mission, it may extend through many years. 

Recovery is more frequent in cases of lateral sclero- 
sis than in many other forms of chronic disease of the 
spinal cord. The disease itself rarely causes death, the 
fatal termination usually occurring in consequence of 
some complication. 

There is no other disease in which such a complex of 
symptoms is found as described above ; the reflex and 
spasmodic phenomena are peculiar, and, so far as 
known, occur only when the lateral pyramidal tracts 
are affected. When these tracts are subject to second- 
ary degeneration, the result of cerebral disease or dis- 
ease of the mesencephalon, similar reflex phenomena 
are observed ; but then the history of the origin and 
progress of the disease will render a diagnosis easy, 
and even without these the hemiplegic character of the 
symptoms would indicate their cerebral origin. 

In multiple sclerosis the lateral columns may be 
chiefly affected, in which case the symptoms peculiar 
to such lesion will predominate, and, if the disease ex- 
tends but little beyond those columns, an error of diag- 
nosis is inevitable. Generally, however, there will be 
other symptoms pointing in the right direction. The 
physician's skill will be tested in unraveling the com- 
plication of symptoms so as to recognize those depend- 



254 DISEASES OF TEE SPINAL CORD. 

ing upon lateral sclerosis and those depending upon 
sclerosis of other parts. 

Treatment. — Comparatively little may be said in 
regard to treatment ; nitrate of silver is recommended 
by some. Erb mentions the galvanic current as afford- 
ing the best results ; he also favors a " reasonably con- 
ducted water treatment " ; indeed, the treatment is very 
similar to that in other cases of chronic myelitis. 



CHAPTER XXI. 

PSETTDO-HYPERTROPHIC PARALYSIS. 

Duchenne, G. B., De l'electrisation localisee, 3 me edit., 1872. 
— Ord, W. M., Notes of a Case of Duchenne's Pseudo-hypertrophic 
Muscular Paralysis. Med. Chir. Trans., 2d Series, vols, xxxix, 
xlii.— Poore, C. T. New York Med. Jour., 1876.— Moore, M. 
Lancet, June 19, 1880.— Gerhard, G. S. Pliila. Med. Times, 
Oct. 16, 1875. — Gowers, Pseudo-hypertrophic Paralysis. Lon- 
don, 1879. 

tEttology. — This disease is almost confined to males, 
very few cases having been seen among females. It is 
not nncommon to find several cases in the same family, 
the boys being affected, and the girls as a rnle escaping. 
When several branches of a family are affected, the dis- 
ease is almost invariably fonnd among the mother's 
relatives, not the father's. 

The subjects of pseudo-muscular hypertrophy are 
children ; very few adults are attacked ; it usually be- 
gins before six years, and sometimes before the child 
learns to walk. Gowers finds that it begins later in 
girls than in boys. 

The conditions or circumstances which cause the 
disease to appear are unknown. 

Symptoms. — The earliest noticeable symptom is 
diminution of motor power : the child either leams to 
walk late, or loses its steadiness and acquires peculiari- 
ties of gait and posture. Notwithstanding this weak- 
ness, the muscles seem to be of good size, especially 
those of the calves, and the parents think it is strange 
that, with such large, plump legs, their children find so 



256 DISEASES OF TEE SPIRAL CORD. 

much trouble in getting about. This apparent hyper- 
trophy may be noticed in other muscles, as those of 
the thigh, the glutsei, more rarely those of the upper 
extremity. Duchenne gives a representation of a pa- 
tient who had enlargement, apparently, of all the mus- 
cles except the pectorals, which were atrophied. 

Slowly the weakness extends and increases ; the en- 
largement of muscles does not extend, but the loss of 
power is usually attended with atrophy, so that the pa- 
tient finally appears reduced almost to a skeleton with 
enormously large legs. 

The loss of power in various muscles leads to pecul- 
iarities of posture and gait which are characteristic. 
The patient, in standing, throws his abdomen forward, 
his shoulders backward, and bends his head slightly 
forward so as to keep his balance. Duchenne thinks 
this posture is caused by weakness of the muscles of 
the back. Gowers ascribes it to weakness of the exten- 
sors of the hip, which causes the pelvis to incline for- 
ward more than normal. When this lordosis is marked, 
if the patient stands, a plumb-line falling from the 
shoulders passes more or less in rear of the sacrum. In 
standing, the patient keeps his feet widely separated, 
and walks with a waddling or rolling gait, which de- 
pends upon the weakness of the glutsei. 

When the weakness has advanced only a little, the 
patients need to help themselves with their arms in ris- 
ing from a chair, and, if the loss of power is consider- 
able, the patient must help himself more, and, so to 
speak, climbs up his own legs. Gowers describes the 
different ways in which patients assist themselves : 
Some put their hands on their knees, then on the 
thighs, grasping them, and the hands are moved alter- 
nately higher and higher until they are upright ; oth- 
ers, to rise from the floor, take a position on hands and 
knees, then on hands and feet, or rather toes, with the 
feet wide apart, then, moving the hands backward on 
the ground till the legs are nearly perpendicular, they 



PSEUDO-EYPERTROPHIG PARALYSIS. 257 

put one hand on one knee, and with a slight spring rise 
upright. 

Fibrillary twitchings are often seen in muscles un- 
dergoing atrophy, as in progressive muscular atrophy. 

Reflex functions, cutaneous and tendinous, suffer, 
apparently, according to the amount of disease in the 
muscles. 

Electrical reactions are diminished in proportion to 
the muscular atrophy and the amount of fat deposited, 
a large increase of fat making it necessary to use a 
stronger current to obtain equal reaction. 

Sensibility is not disturbed, and it is very rare that 
there is pain. 

Mental powers are only exceptionally blunted. In 
a few cases epileptic fits have been recorded ; but, as 
Gowers says, they are probably the result of an associ- 
ated, not of a related, cerebral disease. 

The progress of the disease is slow ; gradually one 
muscle after another is affected, sometimes one side be- 
ing attacked a little before the other, but usually both 
nearly together. There are periods of quiescence, but 
the tendency is steadily onward. When the disease 
commences early, life is not prolonged many years ; 
when later, the patients may live to adult years. Usu- 
ally death occurs between ten and twenty-five. Death 
is usually caused by some intercurrent disease, often of 
the respiratory organs. 

Pathological Anatomy. — The hypertrophied mus- 
cles are found at the autopsy to be largely composed of 
fat ; the muscular fibers are diminished in size and 
widely separated by masses ■ of connective tissue filled 
with fat. Statements of observers do not agree as to 
fatty degeneration of the muscular fibers ; probably it 
sometimes occurs ; they more frequently suffer simple 
atrophy. Finally, the muscular tissue disappears and 
gives place to fibrous tissue. 

Changes in the spinal cord are not constant. Many 
times none have been found, sometimes the cells of the 

17 



258 DISEASES OF THE SPINAL CORD. 

anterior cornua are more or less diseased, and some- 
times the white substance near the gray is diseased. 
Gowers concludes that pseudo-hypertrophic paralysis 
of early life is not a disease of the spinal cord. 

The only constant change found, in all cases, so far, 
has been the muscular degeneration. I am not pre- 
pared to accept Friedreich's views as to the nature of 
the affection. I can not form any satisfactory theory, 
and must leave that for the developments which may 
be learned in the future. 

Diagnosis. — There is no danger of mistaking the 
fully developed disease if care is taken in examination. 
If the legs or thighs are not much hypertrophied, there 
may be some doubt about the nature of the disease, and 
progressive muscular atrophy may be thought to be 
present. In the earliest stage a portion of muscle may 
be removed by a "harpoon," and examined under the 
microscope in order to settle the diagnosis. 

Peognosis. — The most that can be hoped is that the 
disease will cease advancing for a while. What has 
been said in regard to its course and progress will aid 
to an intelligent prognosis. If in any case, however, 
friends desire to know how long a child thus afflicted 
will live, we need to be cautious about giving a definite 
answer. We do not know. 

Teeatment. — The plan recommended for progres- 
sive muscular atrophy is that which is most rational. 
Gowers has obtained slight benefit from arsenic and 
from phosphorus. 



DISEASES OF THE PERIPHERAL 

AND 

SYMPATHETIC NEEVES. 



CHAPTER XXII. 

NEURITIS. 

Mitchell, S. Weir, Injuries of Nerves and their Consequen- 
ces. Philadelphia, 1872.— Niedick, W., Ueber Neuritis Migrans 
und ihre Folgezustande. Arch. f. exper. Pathol., vii, 1876, p. 
205. — Mills, C. K., Traumatic Neuritis involving the Brachial 
Plexus. Philadelphia Med. Times, 1877, p. 564.— Treub, Hec- 
tor, Ueber Reflexparalyse und Neuritis Migrans. Arch. f. exper. 
Pathol., x, 1879, p. 398. — Gombault, Contribution a l'etude anato- 
mique de la nevrite parenchymateuse subaigue et chronique. 
Arch, de nevrolog., i, 1880, pp. 11, 127. 

Multiple Neuritis.— Eichhorst, H. Virch. Arch., 69, 1877, p. 
265. — Leyden. Charite Ann., v, 1880, p. 206.— Stewart. Edin- 
burgh Med. Jour., 1881, vol. xxvi, p. 865.— Caspari. Zeitschr.f. hi. 
Med., 1882, p. 537.— Pierson. Volkmann's Sammlung, No. 224, 
1883.— Strumpell. Arch. f. Psych., xiv, 1883, p. 339.— Muller. 
Ibid., p. 669. — Vierordt. Ibid., p. 678. — Webber, S. G. Archives 
of Med., xii, Aug., 1884.— Scheube, B., Die Japanische Kak-ke 
(Beri-beri). Deut. Arch. f. M. Med., 31, 1882, p. 141 et seq. 

SIMPLE NEURITIS. 

Pathological Anatomy. — The nerve-fibers, or the 
sheath of the nerve, may be the seat of inflammation, 
which may be acute or chronic. When the nerve-fibers 
are affected, the nuclei in the neurilemma are multi- 
plied, the medullary substance divides and undergoes 
a granular or fatty degeneration, the axis cylinder may 
be hypertrophied, but finally is destroyed, and there 
remains only a fibrous band in place of the nerve. When 
the sheath of the nerve, the perineurium, is chiefly af- 
fected, it becomes thickened by formation of new tis- 
sue and the infiltration of serum ; the nerve-fibers are 
compressed, and undergo degeneration secondarily. 



262 DISEASES OF THE PERIPHERAL NERVES. 

In acute neuritis the nerve is rather more congested, 
the nerve-fibers are the more frequently most affected, 
and pus is more likely to form ; sometimes haemor- 
rhages occur into the sheaths of the nerve, leaving 
pigmentation after the blood has been absorbed. 

Chronic neuritis may follow as the result of acute, 
or may occur spontaneously ; the sheath is more likely 
to be the chief seat of the disease, and the nerve-trunk 
is thereby much thickened. The nerve-fibers degener- 
ate and undergo atrophy. 

The nerve beyond the seat of inflammation under- 
goes the secondary Wallerian changes when the fibers 
are entirely severed. 

Trophic changes in the limbs may follow as results 
of the neuritis. 

^Etiology. — Injuries are the most common cause of 
neuritis. All kinds of wounds, bruises, and contusions 
may give rise to the disease ; tumors, abscesses and 
inflammatory changes in the vicinity of the nerve, com- 
pression of the nerve, whether from external or inter- 
nal causes, may give rise to the disturbance. Rheumatic 
thickening of the sheath, from exposure to cold, is a 
very common cause. Neuritis sometimes occurs after 
eruptive fevers or diphtheria, or is the result of syphilis. 

Symptoms. — Pain is the most prominent symptom 
of neuritis, at least in the patient's opinion. There 
may be fever with chills before the pain is felt ; but this 
is not very common. The pain is often severe, of a 
burning character, sometimes more aching in nature ; 
it is felt in the course of the peripheral distribution of 
the nerve ; the limb is hyperresthetic, sometimes a very 
slight touch causing distress ; there is always tender- 
ness over the course of the nerve, especially where it 
is superficial. The pain is continuous, but with sea- 
sons of exacerbation ; often is most severe at night. 

When the nerve is seriously affected, the sense of 
touch is much diminished or lost ; even in rather mild 
cases there is a dullness of that sense, yet the anses- 



SIMPLE NEURITIS. 263 

thetic part may be very tender, and a slight pressure 
may cause pain. 

The pain may prevent motion, but subsequently the 
muscles to which the nerve is distributed lose their 
power, are paralyzed, and undergo more or less wast- 
ing according to the amount of change in the nerve. 
When the nerve is entirely destroyed, the motor pa- 
ralysis is complete, the atrophy extreme, with the reac- 
tion of degeneration. 

When the muscles are only partially paralyzed there 
may be tremor, very closely resembling the tremor of 
sclerosis ; or more extensive spasm and twitching may 
occur. 

After the acute symptoms have subsided, or from 
the beginning in other cases, a chronic neuritis may be 
recognized. The symptoms are the same, though per- 
haps less severe than in the acute, except that there 
is no fever, and at length other symptoms are added. 
The pain may have less of the burning character, but 
be quite as wearing ; often, however, it is only moder- 
ate in degree, and in very mild cases is not present con- 
tinuously ; it is excited or increased by use of the limb. 
The numbness and pricking are the same as when the 
disease is acute. There is always tenderness over the 
affected nerve, which is often swollen. 

The motor disturbance is the same as in acute neu- 
ritis, but may be more slowly develoj)ed ; the reaction 
of degeneration is proportionate to the amount of atro- 
phy ; when the disease is very slight, the electrical irri- 
tability may be increased. Tremor, as in sclerosis, is 
more common than in the acute form. 

Trophic changes in other than the muscular tissue 
are almost always noticed. These have been studied 
especially by Mitchell, and consist in herpetic, vesic- 
ular, and other eruptions, atrophy of the skin, "glos- 
sy skin," with a peculiar hypersesthetic condition, 
"causalgia." The nails may become clubbed, brittle; 
their growth is less rapid. The hair is brittle, may fall 



264 DISEASES OF THE PERIPHERAL NERVES. 

off, or may grow abnormally long, or it may become 
white. 

Acute neuritis may be of short duration, the nerve 
soon recovering its normal condition. Chronic neuri- 
tis persists for many weeks or months, and, when it 
has apparently disappeared, the symptoms are easily 
excited again. 

Neuritis shows a tendency to extend toward the 
nerve-centers, or to pass to adjoining nerves. Not in- 
frequently the inflammation extends until it seems as 
if all the nerves of the limb were affected. I have 
seen this in the arm rather than the leg, perhaps be- 
cause the patients could not or would not give the limb 
the needed rest. This extension is not always by con- 
tinuity ; the inflammation may jump over a stretch of 
healthy tissue. The disease may extend to the cord, 
and thereby death may result. 

Prognosis. — The patient's life is only rarely threat- 
ened when the disease extends to the nerve-centers. 
Perfect recovery is possible when the disease has con- 
tinued comparatively long, if the changes have not 
become too extensive, and even serious and severe 
cases may do well. Many times, however, the tro- 
phic changes in muscles and other structures are so 
considerable that a complete recovery of function is 
not possible ; the symptoms of neuritis disappear, but 
the parts remain partially helpless. In less favorable 
cases more or less pain may be felt at intervals, show- 
ing that the nerve-fibers are still subject to irritating 
influences. A relapse, or a second attack, is not uncom- 
monly the result of comparatively slight imprudence 
in over-exertion or exposure. 

Treatment. — Rest is of great importance in both 
acute and chronic neuritis. The limb affected should 
be kept quiet ; if necessary, the patient should be con- 
fined to bed. If the arm is affected, it may be well to 
secure a splint lightly to the limb. 

In acute cases, cold may be applied constantly over 



SIMPLE NEURITIS. 265 

the seat of the inflamed nerve. A rubber bag, so ar- 
ranged that a stream of cold water will flow continu- 
ously through it, is convenient. 

Galvanism has been advised, and is of benefit in 
some cases. It is not likely to do much good in acute 
cases, and in chronic is often less useful than blister- 
ing ; it may even increase the pain and aggravate the 
symptoms. After recovery is fairly established, and 
the pain has ceased, electricity will be of value in re- 
storing the use of the partially paralyzed muscles. 

In subacute and chronic cases the most efficient 
means is blistering. A blister the size of a ten-cent 
piece or a quarter should be put over the tender points 
in the course of the nerves. If several nerve-trunks are 
affected, one after the other may be thus treated. It is 
not well to apply many at one time. Sometimes the 
pain is worse until a day or two after the blister is 
drawn, when a marked relief will be experienced ; the 
blister seems to be of most benefit while the raw sur- 
face is healing ; for this reason the healing should be 
favored as much as possible by not removing the cuti- 
cle, and by avoidance of irritating ointments and fric- 
tion. 

It may be necessary to control pain by giving mor- 
phia or other narcotics. A four-per-cent solution of 
carbolic acid, applied to the limb on compresses, may be 
useful in relieving the pain. 

Salicylic acid in rheumatic cases, iodide of potas- 
sium, quinine in rather large doses, and, later, cod-liver 
oil and other tonics, would be of value. 

During convalescence, when pain has nearly or quite 
ceased, electricity, massage, passive exercise, or the 
Swedish movement, may be used to restore function 
and increase the nutrition of the limb. 

In syphilitic neuritis, of course the specific treat- 
ment should be used. 



266 DISEASES OF TEE PERIPHERAL NERVES. 
MULTIPLE NEURITIS (Disseminated Neuritis). 

Pathological Anatomy. — The affected nerves 
show no special gross change ; they do not seem to be 
enlarged or congested. Under the microscope the 
nerve-fibers are found to have undergone extensive 
changes. There is inflammation, and below this the 
medullary sheaths, with the axis cylinders, are seg- 
mented, then divided into smaller granular masses, and 
finally these are absorbed. The nuclei increase in 
numbers. There is only a moderate increase of the 
interstitial tissue. 

The muscles show changes due to degeneration — a 
granular appearance ; fat is deposited between their 
fibers, which may undergo simple atrophy; their nu- 
clei are multiplied. 

^Etiology. — Exposure to cold and over-exertion 
are considered important as causes. Certainly many 
patients refer their disease to ' ' catching cold. " Cas- 
pari suggests that multiple neuritis may be an infec- 
tious disease. 

It has been thought by several, who have had op- 
portunity to observe it, that beri-beri, or 7cak-7ce, is a 
multiple neuritis. Scheube has carefully examined 
twenty cases, post-mortem, and reaches this conclu- 
sion. 

Symptoms. — The disease may begin with fever, pre- 
ceded or not by a chill, or the fever may be absent. 
The pulse is habitually rapid throughout the disease. 
Pain and stiffness in the limbs are usually first to at- 
tract the patient's attention — usually the legs, some- 
times the arms, being first affected. Any effort to move 
the limbs increases the pain, which may then be most 
acutely felt about the joints. A hyperesthesia of the 
muscles increases the resemblance to rheumatic fever. 

The pain is almost constant, may be extremely se- 
. vere, is attended with a sensation of tingling or prick- 
ing, or may be of a burning character, as if very hot 



MULTIPLE NEURITIS. 26? 

water were applied to the limb. Sometimes the pain 
seems to be confined to the course of the diseased nerve 
or nerves, or it is generally diffused over the region to 
which the nerve is distributed. Not only is there gen- 
eral hyperesthesia to pressure, but the course of the 
nerve is tender, and, upon pressure over the nerve- 
trunks, the pain is increased in the limb also. 

The sense of touch is diminished in the affected 
parts ; especially is this noticed by the patient after 
the pain has partially or entirely disappeared. 

The muscles supplied by the affected nerves are par- 
tially paralyzed early in the course of the disease, yet 
motion is restricted more by the pain excited than by 
the weakness ; later there may be total paralysis of 
single muscles or groups of muscles. 

The cutaneous reflexes are absent in about half, and 
the patellar tendon reflex is absent in more than nine 
tenths of the cases ; the latter is very late in returning. 

The limbs are more or less flexed, and this position 
may be maintained by contracture of the muscles ; then 
passive extension is very painful. 

The muscles waste and show the reaction of degen- 
eration. This change may occur very rapidly in acute 
cases. Abnormal positions of the fingers and limbs 
may be caused by the wasting, as in other cases of mus- 
cular atrophy. 

Trophic changes may be seen in the skin, occasion- 
ally there is oedema of the limbs, and sometimes ex- 
cessive sweating. 

The inflammation extends more or less rapidly from 
nerve to nerve, not following any regular order, though 
the disease is usually roughly symmetrical, both legs 
or both arms being affected at about the same time. 
The different muscles are not equally paralyzed on the 
two sides. 

Mental and cerebral symptoms are usually wanting ; 
when present, they have seemed to be due to some 
complication ; the suffering has seemed to give rise to a 



268 DISEASES OF THE PERIPHERAL NERVES. 

hysterical condition ; occasionally a mild nocturnal de- 
lirium is noticed. 

The paralysis may extend until so extensive that 
life is threatened, and death may result from paralysis 
of the respiratory nerves. In most cases, however, 
after a time the pain and tenderness diminish and final- 
ly disappear, leaving the anaesthesia and weakness. 
Recovery is slow, delayed by contractions of the limbs, 
and, if the nerve-structures have been seriously dam- 
aged, it may never be complete. 

Diagnosis. — Multiple neuritis is most likely to be 
confounded with anterior poliomyelitis, progressive 
muscular atrophy, lead paralysis, and rheumatic fever. 

The sensory disturbances distinguish it from disease 
of the cells of the anterior cornua of the cord ; these 
and the marked changes in electrical reactions will dis- 
tinguish it from progressive muscular atrophy, where 
there are only very slight electrical changes, simple 
diminution of reaction, and rarely if ever the reaction 
of degeneration. Lead paralysis has many of the symp- 
toms of multiple neuritis ; but, as a rule, the sensory 
disturbance is less severe ; the other signs of lead-poi- 
soning and the elimination of lead by the kidneys un- 
der the use of iodide of potassium are of value in mak- 
ing a diagnosis. 

It is only at the very beginning that neuritis and 
rheumatic fever resemble each other ; the latter is ac- 
companied with a higher temperature, and soon the 
joint affection and the course of the disease will make 
the diagnosis clear. 

Treatment. — During the earlier stages of the dis- 
ease, salicylic acid or the salicylate of soda, in large 
doses, is apparently of most value. Bags of hot water 
to the spine have seemed to relieve the pain ; hot baths 
are said to be helpful. Small and frequently repeated 
doses of aconite are sometimes of value. 

The chief indication at first is to relieve pain. Mor- 
phia should be given as freely as needed. For external 



MULTIPLE NEURITIS. 269 

use, chloroform, or a four- to five-per-cent solution of 
carbolic acid, may be found serviceable. A subcutane- 
ous injection of a two-per-cent solution of carbolic acid 
is recommended by Caspari. If the disease is not 
widespread, blisters might be of advantage. 

Best in bed is, of course, necessary ; massage and 
passive motion should not be attempted till after the 
disease has come to a standstill. The same is true of 
electricity. These agents are, however, of great value 
in restoring their function to the paralyzed muscles; 
the galvanic current is preferable in most cases. Mass- 
age and passive motion should be used systematically 
to overcome the contractures which remain after the 
acute symptoms have disappeared. 



CHAPTER XXIII. 

NEURALGIA. 

Valleix, F. L. I., Guide clu medecin practicien, 1866, t, i, p. 
693. — Anstie, F. E., Neuralgia and the Diseases that resemble it. 
London, 1871.— Trousseau, Clinique medicale. Paris, 1865. (Al- 
so New Sydenham Soc/s translation, 1868.) — Mitchell, S. Weir, 
The Relations of Pain to Weather, etc. Am. Jour, of the Med. Sci. , 
April, 1877, p. 305.— Wood, H. C, The Trigeminal Neuralgias. 
Med. Record, Oct. 27, 1877, p. 673.— Seguin, E. C, Report on 
Aconitia in the Treatment of Trigeminal Neuralgia. N. Y. Med. 
Jour., Dec, 1878. — Ibid., A Contribution to the Medicinal Treat- 
ment of Chronic Trigeminal Neuralgia. N. Y. Med. Record, Jan. 
4, 1879. — Chapman, John, Neuralgia and Kindred Diseases. Lon- 
don, 1873. — v. Pith A, Prof., On the Diagnosis and Treatment of 
Neuralgia. Med. Times and Gaz., 1875, ii, pp. 356, 591.— Eulen- 
burg, Die Osmiumssaurebehandlung der periph. Neuralgien. 
Berl. M. Wochenschr., No. 7, 1884.— Alexander, R. G., Practi- 
cal Notes on Neuralgia and its Treatment. Lancet, June 3, 1882, 
p. 908.— Dujardin - Beaumetz, On the Treatment of Neuralgia. 
Med. News, April 14, 1883, p. 405. — Seeligmuller, A., Lehrbuch 
der Krankheiten der peripheren Nerven, und des Sympathicus. 
Braunschweig, 1882. 

Neuralgia is the name given to an affection of which 
the chief symptom is pain. This pain is of variable 
intensity and character, it follows the course of the 
affected nerve and its branches, occurs in paroxysms 
with periods of more or less perfect remission or even 
intermission, and is not dependent upon any discover- 
able organic lesion. 

Symptoms. — The essential symptom of neuralgia is 
pain, which may be confined to a limited region, or 
may follow the course of the nerve and its branches, 
even radiating into other nerve-districts. The char- 



NEURALGIA. 271 

acter of the pain varies ; the superficial cutaneous 
branches are the most frequently affected, though the 
pain is sometimes deep-seated, and the visceral nerves 
may suffer. The pain may be very light, and cause 
very little discomfort ; or may be severe, lancinating, 
cutting, tearing, burning, boring, twisting. Patients 
use different words in describing the attacks, and there 
is probably a difference in the character of the pain, 
though in a severe paroxysm one is scarcely able to 
make a very nice distinction, and so the patient uses 
that term which occurs to him at the time as most ex- 
pressive. 

Before an attack of neuralgia the patient may be 
conscious of impaired general health ; or there may be 
more direct warning in a period of discomfort, a sense 
of weariness, of weight, or tingling, or some abnor- 
mal sensation in the parts about to be affected. Slight 
twinges of pain, which are really less severe attacks, 
precede the more severe ; twitching, tremors, and slight 
loss of power, may be among the prodromes. Similar 
phenomena may precede each attack of neuralgia, so 
that the patient learns to anticipate it. 

In other cases the pain suddenly bursts out and 
overwhelms the patient's fortitude by its severity and 
its unexpected onset. These sudden attacks are proba- 
bly rare in the early stage of the disease, but are less 
rare after several attacks have followed one another 
with intervals of entire intermission. 

Between the paroxysms there may be less severe 
pain, which is then more frequently of an aching, burn- 
ing, or pricking character. 

The duration of an attack may vary within very 
wide limits ; paroxysm after paroxysm succeed each 
other with almost lightning-like rapidity, and even in 
the intervals the pain is very intense, so that the whole 
series of paroxysms may be looked upon as one attack. 
At another time there is only one sharp sting of pain. 
The attacks may recur several times an hour or day, or 



272 DISEASES OF TEE PERIPHERAL NERVES. 

may be absent for days or months. An extended pe- 
riod of freedom from all pain is rare in a patient veiy 
much affected. In severe cases remissions are more 
common than intermissions. The first attacks are often 
comparatively light, and the severity of the pain gradu- 
ally increases as the attacks multiply. 

The pain is always felt either at one point of a nerve 
or along the course of a nerve. Not infrequently a 
patient unacquainted with anatomy will map out the 
affected nerve and its branches. The locality of the 
pain may be different in the different attacks, shifting 
perhaps to the opposite side of the body. When the 
pain always affects the same nerve, there is a strong 
probability that it is due to an organic lesion of that 
nerve. 

In the beginning of the disease, and in uncompli- 
cated cases throughout, there is no elevation of tem- 
perature. 

When one nerve has been long the seat of pain, there 
is usually a loss of acuteness in common sensibility of 
the skin, and an increase in acuteness to sensation of 
pain. Certain points become tender, so that a very 
light touch is painful. These points, points doulou- 
reux, were specially studied by Valleix, and are some- 
times named from him. They are found where the 
nerve passes through bony canals, or through fasciae, 
becoming thus superficial. These points may not be 
painful when the disease has but recently commenced ; 
sometimes they are entirely wanting. If the pain is 
clearly intermittent, they may not be tender to pressure 
during the intermission. It is not uncommon to find 
the spinous processes of the vertebrae, between which 
the affected nerves pass, painful upon pressure, points 
apophysaires. 

The pain of neuralgia is increased by all motions of 
the affected parts ; thus, motions of the jaw in chewing, 
or of the face in talking and laughing, will increase the 
severity of facial neuralgia ; so walking will render the 



NEURALGIA. 273 

suffering more severe in sciatica. Necessarily, there- 
fore, under such conditions, neuralgia will interfere 
with motion. 

Besides the above causes of immobility, there may 
be actual weakness of the muscles, a partial paralysis. 
Twitchings, tremor, and even more severe spasms of 
the muscles, may attend the paroxysm as well as pre- 
cede it. 

There may be changes in the circulation or the nu- 
trition of the affected parts. The arteries are at first 
contracted, and the skin is pale ; later, relaxation of 
the vessels gives rise to a more congested appearance, 
and there may even be a tendency to cyanosis. (Ede- 
ma is sometimes noticed in the limbs or face. The se- 
cretions may also be altered, the tears flow freely, and 
the saliva and urinary secretions are abundant. 

Decided trophic changes are usual in old, obstinate 
cases, especially in neuralgia of the limbs ; the muscles 
are wasted more than can be explained by their lack of 
exercise. This wasting has been explained by the 
changes in the nerve which give rise to the pain, peri- 
neuritis, or by supposing a change in the circulation of 
the cord, and hence disturbance of nutrition in the 
motor cells of the anterior cornua. 

Cutaneous eruptions, herpes, erythema, pemphigus, 
urticaria, and psoriasis may be found among the com- 
plications of neuralgia. The skin may become thick- 
ened, and the hair may change color. 

Except in severe and long-continued cases, the gen- 
eral health and disposition rarely suffer. Persistent 
and extreme pain, however, impairs the digestion, dis- 
turbs sleep, prevents exercise, taxes the endurance, and 
at length there is evident a disturbance of the general 
health ; the temper becomes more irritable and peevish, 
mental power may be weakened, and finally there may 
be insanity. This is rare, as the i^atients usually quick- 
ly regain health when there is even temporary relief 
from pain. 



274 DISEASES OF THE PERIPHERAL NERVES. 



TRIFACIAL NEURALGIA (Prosopalgia) 

Is one of the most common forms of neuralgia. As the 
branches of the fifth nerve pass through bony canals 
they are much more readily compressed by a very slight 
swelling of their sheaths, and the pain thus produced 
is proportionately severe. 

Exposure to cold, decayed teeth, and exostosis are 
likely to be among the causes ; but disturbance of the 
stomach, intestines, generative organs, and other dis- 
tant parts, may give rise to the disease. 

The symptoms are such as have been already de- 
scribed. The pain is often excessive; spasm of all the 
muscles of the affected side of the face is excited by 
the agony. The painful points are the palpebral, at 
the external part of the upper eyelid ; the supra- 
orbital, where the frontal nerve turns up over the edge 
of the brow ; the nasal, at the upper part of the nose ; 
the malar ; the infra- orbital, at the point of emer- 
gence of the infra-orbital nerve ; the mental, where the 
inferior maxillary nerve ends in the mental and passes 
out from the foramen. There are less important points 
mentioned: the ocular; the labial ; the lingual; the 
parietal, which is common with the cervico-occipital 
neuralgia. The points apopliysaires are found over 
the spinous processes of the first and second cervical 
vertebrse and the occipital protuberance. 

The conjunctiva of the eye on the affected side, and 
sometimes of the opposite eye, may be deeply con- 
gested, tears may flow freely, and the nasal mucous 
membrane may secrete profusely. The pupil is often 
dilated. 

CERVICO-OCCIPITAL NEURALGIA 

Is seated in the region to which the first four cervical 
nerves (cervical plexus) are distributed. This includes 
the back and side of the head as far forward as the ear, 
the neck and apex of the shoulder, and posterior part 



DORSO-INTERCOSTAL NEURALGIA. 275 

of the lower jaw. The painful points are the occipital, 
between the mastoid process and the first vertebra ; the 
mastoid, over that process close to the ear near the exit 
of the seventh nerve ; the parietal, in common with 
trifacial neuralgia, and sometimes the rim of the ear is 
tender. The points apophysaires are over the four 
upper cervical vertebrae. 

It is important not to mistake the pain caused by 
caries of the upper cervical vertebrae for this form of 
neuralgia. 

When the nerves of the brachial plexus are involved 
we have cermco-brachial neuralgia. This is more fre- 
quently traumatic in origin. The painful points are. 
found in the axilla, over the median nerve at the elbow, 
the ulnar just above the elbow, the radial where it fol- 
lows round the humerus, at the lower angle of the 
scapula, and at the lower end of the ulna. The points 
apophysaires are over the lower cervical and upper 
dorsal vertebrae. 

Many times there is really chronic neuritis as cause 
of the pain. 

DORSO-INTERCOSTAL NEURALGIA 

Is a very frequent form. The thoracic nerves are in- 
volved ; it is rather more frequent on the left side ; it is 
one of the accompaniments of various pulmonary dis- 
eases ; is common in phthisis. Herpes zoster is very 
common around the chest ; it may be excited by dis- 
turbances of the abdominal viscera, especially of the 
stomach. 

The painful points are found just to the side of the 
vertebrae ; then near the center of the course of the in- 
tercostal nerves ; and, anteriorly, the region of terminal 
expansion, as Trousseau calls it. In tracing the nerve, 
the curvilinear course of the ribs should not be forgot- 
ten. The points apophysaires are found over the ver- 
tebrae corresponding with the affected nerve. 

Infra-mammary neuralgia is one variety of inter- 



276 DISEASES OF THE PERIPHERAL NERVES. 

costal, which gives much annoyance and causes much 
suffering, exciting, also, fears in the patient of inflam- 
mation of the breast. 

When intercostal neuralgia is severe, the respiration 
is disturbed, rapid, and painful ; the pain radiates to 
the arm ; there is palpitation, and angina pectoris may 
be closely simulated. 

LUMBO-ABDOMINAL NEURALGIA 

Is the name given to the disease when the crural plexus 
is the seat of pain. The painful points are near the 
spinal column ; just above the crest of the ilium, near 
its center : above the pubis ; near the lower part of the 
rectus muscle ; there may be points in the vagina or 
about the scrotum ; over the anterior-superior spinous 
process ; over the crural nerve as it passes out from un- 
der Poupart' s ligament ; on the inside of the knee-pan ; 
and over the saphenous nerve in front of the ankle. 

Sometimes congestion and haemorrhages from the 
uterus and vagina seem to depend upon this neuralgia. 
The pain may lead to a suspicion of uterine disease. 
Lumbago may be distinguished by the fact that mo- 
tion causes pain, which is absent during complete quiet. 
The pain caused by renal calculi may be mistaken for 
neuralgia. 

SCIATICA 

Is one of the most common, most rebellious of neural- 
gias ; it is rather more frequent in men. In the ma- 
jority of cases there is a neuritis. Between the par- 
oxysms of pain there is usually an aching or burning 
sensation ; a heavy, bruised feeling. Exertion will of- 
ten cause a relapse. 

The painful points are : near the sacrum ; where the 
nerve emerges from the pelvis ; near the great trochan- 
ter of the femur (Erb considers this the most constant) ; 
at the lower border of the gluteus muscle ; in the pop- 
liteal space ; frequently the whole course of the nerve 
in the thigh is tender, and it can be felt to be enlarged ; 



SCIATICA. 277 

just below the head of the fibula ; behind the outer 
ankle. 

Wasting of muscular tissue of the leg is not uncom- 
mon in cases of long standing. 

JEtiology. — Anstie considered every case of neu- 
ralgia to be one of debility. This is somewhat too 
sweeping a statement, yet it is true of most patients 
suffering from this affection that they are below par in 
physical or nervous strength. 

Heredity is an important factor in the aetiology of 
neuralgia. A large proportion of the patients are born 
with less than the normal nervous stamina ; the parents 
may not have neuralgia, but the children have less than 
normal strength and vigor. Much might be written on 
this division, but it is scarcely necessary. 

Women are more subject to some forms than men ; 
some authors consider that the majority of patients are 
women, and this is probably true, though Axenfeld 
says the difference is less than is usually supposed. 

Children rarely have neuralgia. The most suscepti- 
ble age is middle life. The more marked the heredi- 
tary tendency, the earlier the disease will be likely to 
appear. 

It is necessary only to mention that a predisposition 
to neuralgia may be fostered, or even developed, by hy- 
gienic surroundings, by overwork, by anxiety, grief, 
etc. These influences are much the more powerful in 
youth, yet do not lose their power in adult years. 

Acute and chronic disease may bring the system 
into such a state of anaemia or debility as to greatly 
favor an outbreak of neuralgia. 

Among exciting causes, " catching cold " maybe 
the most frequent. Exposure to wet and cold is often 
mentioned by patients as the cause, and probably with 
truth. In such cases there is many times a rheumatic 
thickening of the nerve-sheath, and the disease is really 
a neuritis. It is not always possible to recognize this 
by the symptoms. The nerves most exposed to this 



278 DISEASES OF TEE PERIPHERAL NERVES. 

injurious influence are those of the face, the sciatic, 
and less frequently those of the arms. Many patients 
suffer from sciatica after sitting on a stone or a metallic 
seat. 

Injuries of nerves or in their vicinity may be a cause 
of the disease. A slight injury may give rise to neu- 
ralgia only after months or years. Sometimes in such 
cases a change in the sheath, a thickening, has been 
slowly taking place, until at last, either spontaneously 
or as the result of a forgotten exposure, the attack of 
pain follows. 

Tumors, exostoses, caries of teeth, disease in tho- 
rax or pelvis— these and other changes near nerves, by 
pressure or extension of inflammation, may cause pain, 
and the exciting cause may not be discovered, owing to 
its hidden location. Such cases are not, properly speak- 
ing, cases of neuralgia, yet the diagnosis of the true 
cause of the pain may be impossible. 

Neuralgia may be excited in a reflex way by dis- 
eases of the viscera ; this is especially so in regard to 
the genito-urinary and digestive organs, and in regard 
to caries of the teeth. 

Several poisons, as mercury, copper, lead, alcohol, 
and tobacco, are both predisposing and exciting causes ; 
the same may be said of malarial influences. Syphilis 
is an active agent in many instances, but not so often a 
cause of neuralgia as of headache. 

Pathogenesis. — From the definition of neuralgia, it 
is evident that there can be no special pathological 
change in the nerves. Many times, doubtless, neuritis 
is called neuralgia, and that name is given to other con- 
ditions where organic changes are found. It is proba- 
ble that very many cases of neuralgia ought to have 
another name ; but this is the result of ignorance or 
carelessness on the part of the observer. 

Anstie advocated that every case of neuralgia is 
in reality a case of anaemia of the spinal centers, with 
atrophy of the posterior nerve-roots. Chapman claims 



NEURALGIA. 279 

that congestion of the spinal cord is the cause of the 
pain. 

The truth is that we do not know definitively the 
nature of this affection. It would be easy to quote au- 
thors to show the varying views held in regard to this 
subject, but it would be of doubtful advantage. 

Diagnosis. — Erb gives six characteristic symptoms 
of neuralgia : 1. The pain is limited to a definite nerve- 
path, or area of distribution, and is usually unilateral. 
2. Without any clear reason, the pain is either inter- 
mittent or distinctly remittent. 3. The pain is very 
peculiar and acute. 4. Certain spots in the course of 
the nerve, or in the area of its distribution, are very 
sensitive to pressure. 5. The pain is associated with 
certain sensory, motor, vaso-motor, and secretory phe- 
nomena. 6. The pain is not accompanied by any in- 
flammatory or local symptoms, or any general disturb- 
ance of health at all corresponding with the amount of 
subjective disorder. 

These six diagnostic marks are only presumptive of 
neuralgia. A very large proportion of cases are proba- 
bly neuritis, and it may be as well to recognize the fact 
in practice. 

The pains of locomotor ataxia are very much the 
same as those of neuralgia, and it is necessary to bear 
this in mind. 

Caries of the vertebrae may give rise to pain which 
can be easily mistaken for neuralgia ; the same is true 
of other diseases of the spine or spinal membranes, of 
cerebral lesions, and of malignant growths in the tho- 
racic and abdominal cavities. In all these cases a care- 
ful study of symptoms may lead to a correct diagnosis ; 
but without this, serious mistakes must be made. 

Prognosis. — Unless there is a neuritis or a morbid 
growth, pressing upon the nerve, recent cases are usu- 
ally readily relieved ; but there is a great probability 
of return. The greater the number of attacks, and the 
more localized the x>ain, the less probable is relief, be- 



280 DISEASES OF THE PERIPHERAL NERVES. 

cause under such circumstances there is almost always 
a neuritis or a perineuritis. The most rebellious cases 
are those affecting the fifth and sciatic nerves. 

Treatment. — In neurotic subjects the treatment of 
neuralgia should begin before the pain appears — that 
is, much can be done to prevent its development. The 
young child should be fed and educated, its habits 
formed with special regard to the possible occurrence 
of nervous disorders. This regimen should be all the 
more carefully followed after the affection has appeared. 
Light, air, exercise, and food are necessary in large meas- 
ure. Over-feeding is sometimes of great value ; fre- 
quent feeding, hourly, is one means of inducing the 
system to receive more than it would from the usual 
number of meals. 

So far as possible, all causes should be avoided ; 
warm clothing will aid much ; keep the feet dry. 

Any disease which may give rise to neuralgia should, 
of course, be treated ; this is self-evident, yet easily 
forgotten in the presence of the pain of an attack. 
Teeth should be looked after. Dyspeptic or other vis- 
ceral disturbance, and uterine disorders, attended to. 
Alcohol and tobacco should be stopped. 

It is scarcely necessary to mention that metallic poi- 
sons should be eliminated if possible. In syphilitic 
patients a corresponding treatment must be followed. 

Internally, quinine is often of benefit, not only in 
cases due to malarial poisoning, but where there is no 
such taint. In recent cases, given in moderately large 
doses, five grains every hour until the head aches or 
the ears are affected, it will frequently cut the attack 
short. It is also useful as a tonic to prevent recur- 
rence. Anstie found it useful in affection of the oph- 
thalmic division of the fifth nerve. 

Cod-liver oil, or other form of fat, cream, or butter, 
is very valuable. Many patients find the oil disagree- 
able. Begin with half or quarter of a teaspoonful, to 
which a little salt may be added ; continue this dose, 



NEURALGIA. 281 

after meals, until there is no regurgitation of the fumes 
of the oil ; then the dose can be rapidly increased to a 
tablespoonful. Phillips's emulsion is very palatable. 

Iron in its various preparations is indicated, espe- 
cially in angemic and chlorotic subjects. The tincture 
of the chloride is one of the most valuable forms. An- 
stie recommends very highly a mixture of this with 
strychnia, ten minims of the iron tincture with ^ grain 
of the strychnia. The soluble saccharated oxide of iron, 
in doses of half a teaspoonf ul, is a very pleasant prepa- 
ration. 

Arsenic is valuable in the same cases as the iron ; it 
is also useful in malarial cases. 

Iodide of potassium, or the syrup of hydriodic acid, 
is useful not only in syphilitic neuralgia, but also in 
rheumatic ; colchicum may help in such cases, though 
the bowels should not be too strongly acted upon. 

Phosphorus has been very highly praised, especial- 
ly by many English physicians. Mr. Thompson ad- 
vised it in large doses, not less than -^ grain ; he ad- 
vised -jJg- grain every four hours ; after six doses, -^ grain 
at the same interval. After forty-eight hours, if no re- 
sult, he thinks some good may be effected by increas- 
ing the dose still further. This dose rarely causes trou- 
ble, yet occasionally a patient is unusually susceptible, 
and acute poisoning has been observed ; caution is, 
therefore, necessary. 

Gelsemium, fluid extract, in ten- to twenty-minim 
doses, or tincture, in half-drachm doses, is very service- 
able in facial neuralgia, and perhaps in intercostal and 
ovarian. The preparations of this drug are sometimes 
inert. The dose may be repeated every half-hour, but 
it is prudent not to give more than three doses so near 
one another. 

Croton chloral has been used in facial neuralgia with 
very good results by many ; but I have never seen any 
special benefit from it. 

Aconitia is a very valuable drug ; it is especially 



2S2 DISEASES OF THE PERIPHERAL NERVES. 

useful in angina pectoris, in intercostal and facial neu- 
ralgia, but is of benefit in any form of reflex or consti- 
tutional neuralgia. The pure alkaloid, made by Pu- 
quesnil, crystallized, should be used, or the effect will 
be uncertain. The dose varies from -^ to -j^- grain. 
Dr. E. C. Seguin recommends the following formula : 

# Aconitire (Duquesnil's) g r - tjt ~i j 

Glycerine ) _ . fl _ . 

Alcohol f aafl3j; 

Aq. menth. pip q. s. ut ft. fl 5 ij. M. 

S. A teaspoonf ul two or three times a day, on an empty 
stomach. 

This may be given even more frequently, as often as 
every two hours, if the effects are carefully watched ; 
so soon as the pulse is affected, or there is tingling of 
the lips, tongue, or fingers, the drug must be discon- 
tinued. 

Fereol found sulphate of copper, - 05 to "10, of value 
in epileptiform neuralgia. 

Other drugs that have been used are chloride of 
gold and sodium, nitrite of amyl, chloride of ammo- 
nium, strychnia, which is praised by Anstie, and phos- 
phide or oxide of zinc. 

During the attack of pain, to relieve the distress it 
may be necessary to use morphia or other preparation 
of opium, Morphia subcutaneously is the most effica- 
cious ; but care is needed lest the morphia habit should 
be formed. In old and obstinate cases the smallest 
dose which will relieve the pain, ^ or ^ grain, should 
be used only when it is necessary to give such relief. 
In recent cases one large dose will sometimes work a 
cure. 

Atropia subcutaneously will frequently give as much 
relief as morphia ; -^ grain is usually the largest dose 
necessary. Anstie recommends atropia, especially for 
ophthalmic neuralgia. 

Chloroform, in doses of five to ten minims, injected 



NEURALGIA. 283 

under the skin in the vicinity of the affected nerve, 
often gives relief. 

Schultz used carbolic acid, two to one hundred of 
distilled water, subcutaneously, injecting from a quar- 
ter of a drachm to a drachm of the solution. 

Eulenburg injected a one-per-cent solution of osmic 
acid with benefit in recent cases, which were probably 
neuritic or perineuritic. 

The subcutaneous injection of a drachm of hot wa- 
ter near the nerve — of course not so hot as to scald the 
tissues — will frequently give as much relief as small 
doses of morphia. Acupuncture, passing a needle into 
the skin until the point is near the nerve, will give 
relief in many cases. The needle should be worked in 
slowly and gradually, as near the nerve-trunk as pos- 
sible ; if its point can just touch the nerve, which may 
be known by the peculiar sensation, and then be 
slightly withdrawn, the result is the better. This prob- 
ably is most efficacious in recent cases. 

Various external applications will soothe the pain 
during an attack, and render the use of morphia less 
necessary. Hot water is useful ; so, too, is spirit of 
turpentine. Chloroform, diluted more or less with al- 
cohol, applied on a piece of flannel and covered with a 
towel wet with water, eases the pain. Generally one 
part of chloroform to seven of water is a good mixture, 
though one stronger is often better. Veratria oint- 
ment can be used, but aconite is better. The tincture 
of aconite may be used freely, or the ointment may be 
applied over the affected surface. The ointment of 
aconitia, if made with Duquesnil's aconitia gr. j to 3 j 
lard, will be stronger than the regular officinal oint- 
ment. Care must be taken not to get any of this into 
the eyes, nose, or mouth, and not to rub it where the 
skin is abraded. The person who applies it should 
not use his uncovered hands. A portion half as large 
as a small pea is sufficient for one application. I know 
of no simple external application of equal value. 



234 DISEASES OF THE PERIPHERAL NERVES. 

Blisters over the tract of the nerve, especially over 
the points douloureux and over the points apophy- 
saire, not only give relief, but often effect a cure. The 
blisters need not be large ; an inch by an inch, or inch 
and a half, is sufficient. They may need to be repeated 
over different points, or near the same spot. 

The actual cautery over the same spots may be 
even more valuable than blisters — may give immedi- 
ate relief without so much discomfort. 

Electricity is a most satisfactory agent in many 
cases. Sometimes the faradic, applied through a wire 
brush to the seat of pain, gives immediate relief. The 
galvanic current passed through the affected nerve or 
limb is usually the better. It should be used daily, 
with as little shock or variation of strength as possi- 
ble. 

Vibration communicated to the nerve at the seat of 
pain, by rapid percussion over the tender points, some- 
times gives permanent relief. The percussion may be 
made by means of rubber balls attached to handles, or 
by mechanical contrivances. 

The application of ice by means of the rubber ice- 
bag to the spine, either a portion or the whole, as ad- 
vised by John Chapman, is soothing and grateful. If 
properly applied, it has a tendency to restore warmth 
to the feet, and will relieve pain. It should be applied 
from thirty to sixty minutes several times a day. Oc- 
casionally Chapman uses hot water over the upper part 
of the spine in facial neuralgia with hypereemia or 
swelling of the face. 

Surgical operations are sometimes needed to cure 
neuralgia ; these are excision of portions of nerves, 
which has been frequently done for facial neuralgia, 
and stretching of nerves. The latter is of compara- 
tively recent date, and has given very good results. 
Patruban has tied the carotid for facial neuralgia with 
success in many cases. 



CHAPTER XXIV. 

LOCAL AND POST-FEBEILE PAEALTSES. 

Leyden, Ueber Keflexlahmung. Volkmanri's Sammlung, No. 
2, 1870.— Feinberg, Ueber Eeflexlahmung. Berl. hi. Wochen. , 1871. 
— Panas, De la paralysie reputee rheumat. du nerf radial. Arch, 
gen., 1872. — Webber, S. G., Cases of Peripheral Paralysis : their 
Causes and Nature. Boston Med. and Surg. Jour., Dec. 18, 1873. 
— Bernhardt, M., Zur Pathologie der Kadialisparalysen. Arch, 
f. Psych., iv, 1874, p. 601. — Comegys, Facial Paralysis and Laby- 
rinthine Vertigo. Med. Record, April 24, 1880, p. 445.— Joffroy, 
A., Paralysie radiale. Theorie de la compression. Arch, de 
physiol., Mai, 1884, p. 478. — Westphal, C, Ueber eine Affec- 
tion des Nervensystems nach Pocken und Typhus. Arch, fur 
Psych., iii, 1872, p. 376. — Landouzy, L., Des paralysies dans les 
maladies aigues. Paris, 1880. — Dejerine, J., Eecherches sur les 
lesions du systeme nerveux dans la paralysie diphtheritique. 
Arch, de phys., x, 1878, p. 107.— Wood, H. C, Diphtheritic Pa- 
ralysis. N. Y. Med. Jour., Dec. 29, 1883, p. 705.— Kidd, P., A 
Contribution to the Pathology of Diphtheritic Paralysis. Med.- 
Chir. Trans., vol. lxxxiv, 1883, p. 133. 

PERIPHERAL PARALYSIS. 

By peripheral paralysis may be understood paraly- 
ses which, depend upon lesions of the muscles them- 
selves, or the nerves after they leave the spinal cord. 

vEtiology. — Among the causes may be mentioned 
injuries from falls or blows, or wounds ; pressure upon 
nerves, either by the position of the limbs or by bur- 
dens carried so as to press upon the nerves ; or by tu- 
mors, or other products of disease. 

Cold is a common cause of certain forms of paraly- 
sis, so-called rheumatic paralysis. Disease of neigh- 
boring parts, even when the nerves are not directly 



286 DISEASES OF THE PERIPHERAL NERVES. 

implicated, may give rise to loss of motion, as in hip- 
disease, there is loss of power in the mnscles of the 
leg, which may be attended with atrophy. 

Acnte diseases are many times followed by paraly- 
sis. Certain poisons, as lead, arsenic, and some vege- 
table poisons, canse paralysis, apparently due to dis- 
turbance of the nerves. The same, also, may be said 
of syphilis, though with this there is generally a for- 
mation of new tissue around the nerves. 

Over-exertion of limbs, exhaustion, may lead to 
temporary paralysis, or even to a more serious and 
more permanent loss of motion. 

In some cases the paralysis is spoken of as reflex, 
as if it arose from disease of certain organs by reflex 
action through the spinal cord. It is rather doubtful 
whether such paralyses are really reflex, as is claimed, 
and do not, rather, depend upon disease either of the 
nerves themselves or of the spinal cord. 

Symptoms. — As most of the nerves are mixed 
nerves, there is usually loss of motion and disturb- 
ance of sensation. Sometimes pains or peculiar numb 
feelings and unpleasant sensations precede any loss of 
power ; but very soon, if not at the same time with the 
disturbance of sensation, the patient recognizes that 
there is loss of power. He finds that he can not per- 
form certain acts as readily as formerly. 

The nature of the disturbance of motion will de- 
pend, of course, upon which nerve is affected. If the 
paralysis is not complete, the ordinary reflexes may not 
be seriously impaired ; but if there is entire loss of 
either motion or sensation, both the superficial and 
deep reflexes will disappear. 

In every case of paralysis depending upon a lesion 
of the nerve itself, the electrical reactions will be such 
as have been described under the name of the reaction 
of degeneration. 

Frequently the paralysis is attended with a moder- 
ate decree of swelling of the affected limb, due to a 



PERIPHERAL PARALYSIS. 287 

loss of tone in the blood-vessels on account of paralysis 
of the vaso-motor nerves, which accompany the nerves 
of motion and sensation. For the same reason there 
may be at first a rise of temperature in the limb, though 
subsequently the temperature is lowered, and the limb 
may have a cyanotic appearance. 

Certain trophic changes are found after injuries and 
serious lesions of the nerves. These affect the nerves 
themselves, the muscles, and the skin. The nerves un- 
dergo a degeneration ; the medullary sheath breaks up 
into granular material, which is absorbed, the axis 
cylinder also undergoing a change. The muscles lose 
their striated character, and after a while are changed 
into fatty debris, which is finally absorbed. Accom- 
panying these changes, there is usually more or less 
multiplication of nuclei. 

The skin may be covered with an erythematous 
eruption, or the eruption may be vesicular. Herpes 
and eczema are not uncommon. Sometimes the skin is 
thickly covered with minute scales of epithelium, which 
can be readily brushed off. 

Mitchell has described the glossy skin which is 
found frequently after nerve-lesion. This is most com- 
monly seen in the fingers, perhaps in the foot. The 
skin has a peculiar shiny appearance, without wrinkles, 
without hairs. When the fingers are affected, they ta- 
per off to their ends, and it is very common to have a 
severe pain as an accompaniment of this condition, cau- 
salgia. Occasionally ulcers form, mal perf orant, though 
this is comparatively rare. The nails become brittle, 
rough, and deformed. The hair may fall out, or grow 
to an inordinate length, and sometimes loses its color, 
becoming gray or white. 

Diagnosis. — The diagnosis between paralysis of 
peripheral origin and of central origin must be made in 
large part from the other symptoms. Electricity is the 
most valuable agent in forming the diagnosis. If there 
is the reaction of degeneration, it is certain that either 



288 DISEASES OF THE PERIPHERAL NERVES. 

the nerves are diseased or the large cells of the anterior 
cornua of the spinal cord have undergone degeneration. 
If, then, a disease of the spinal cord can be excluded, 
the diagnosis is clear. 

Multiple neuritis has been already considered. 

Prognosis. — A very large number of cases of pe- 
ripheral paralysis recover completely. The more se- 
vere, however, the original injury, or the more com- 
plete the degeneration of the nerve caused by disease, 
the slower will be recovery, and the more likely per- 
manent impairment of motion will result. 

Among the most favorable cases are those which 
arise from simple pressure, from rheumatic disturb- 
ance, or from poisons and from syphilis. 

Even where the reaction of degeneration is found, 
recovery is not to be despaired of, and treatment should 
be persevered in for many months. The less perfectly 
the reaction of degeneration is established, the more 
favorable is the indication. When secondary contrac- 
tion has set in, or when the reaction of degeneration 
has evidently continued for many months, the progno- 
sis is very unfavorable. 

Treatment. — The treatment of these paralyses 
must be directed first, of course, to a removal of the 
cause if possible. Injuries and other diseases should 
receive their appropriate treatment. If tumors can be 
removed without destruction of a nerve, in course of 
time the paralysis will disappear. 

In cases of exhaustion, rest is sometimes sufficient 
for recovery ; if not, then the same means should be 
used as in other cases of protracted paralysis. In cases 
of syphilis, the anti-syphilitic treatment should be vig- 
orously pursued. Warmth to the limb is quite impor- 
tant. Electricity is of more value than any other agent. 
The galvanic current should be used, the current being 
slowly interrupted, the negative pole being placed over 
the motor points of the affected muscle. In cases of 
paralysis due to pressure or exhaustion, or after acute 



PERIPHERAL PARALYSIS. 289 

diseases, this is usually sufficient. In cases of rheu- 
matic paralysis it may be well, also, to paint over the 
affected nerve with tincture of iodine. Where, how- 
ever, there is reason to suspect that a neuritis has oc- 
curred, small blisters placed over the nerve, as described 
under neuritis, will hasten the cure. 

Internal remedies are of little or no value so far as 
the paralysis is concerned ; they may be required, how- 
ever, for the genera] health and condition of the pa- 
tient. 

SPECIAL FORMS OF PARALYSIS. 

The nerves which move the eye are frequently sub- 
jected to pressure and injury from syphilitic disease of 
surrounding parts, especially of the membranes of the 
brain ; and, as these nerves pass through the bony ca- 
nals at the base of the skull, they are easily com- 
pressed, not only by such growths, but also by the in- 
fluence of cold, producing a congestion and swelling 
and inflammation of the surrounding tissues. 

When these nerves are paralyzed, vision will be more 
or less interfered with. If the third nerve is affected, 
the drooping of the eyelid and loss of power of ac- 
commodation may disturb vision, even when the mo- 
tions of the eyeball seem to be perfect. When the 
muscles of the eyeball are paralyzed, in consequence of 
injury to their nerves, there is more or less immobility 
of the eye, and hence strabismus results. A very care- 
ful description of the various forms of strabismus may 
be found in Ziemssen's "Cyclopaedia," vol. xi, or in 
Ross's work on the " Diseases of the Nervous System," 
or in books on diseases of the eye. 

The seventh nerve; the facial nerve, is perhaps more 
frequently affected by the so-called rheumatic pa- 
ralysis than any other nerve of the body. Passing 
through a bony canal near the ear, being very super- 
ficial where it leaves that canal, it is specially exposed 
to such a disturbance. Draughts of air while riding, 
or sitting at an open window, or other exposure of one 

19 



290 DISEASES OF THE PERIPHERAL NERVES. 

side of the face, may be sufficient to give rise to this 
paralysis. 

As the seventh nerve passes through the temporal 
bone, separated by a very thin lamina of bone from the 
tympanic cavity of the ear, it is very liable to disturb- 
ance in cases of inflammation of the middle ear. New 
growths in the ear may also, by pressure, cause absorp- 
tion of the thin layer of bone, and press upon the 
nerve. Blows upon the side of the head, and other in- 
juries, may likewise result in facial paralysis. 

As the facial nerve is at its origin exclusively a 
nerve of motion, when it is paralyzed the symptoms 
are chiefly those of loss of motion ; in its course, how- 
ever, through the Fallopian canal it receives a few 
branches — one of special sense, of taste, and another, 
near its exit from that canal, of common sensation. 
The auricular branch, from the vagus, passes through 
the temporal bone, quite near the facial nerve, and 
gives a small branch to it. Probably in consequence 
of the proximity of this nerve, many times the first 
symptom of facial paralysis is pain in the region of the 
ear, and generally there is more or less discomfort, if 
not actual pain, during the early part of the disease. 

The most common symptom in paralysis of the 
seventh nerve is loss of power in all the muscles on 
that side of the face. Not only those of the lower part 
of the face, which are affected in cases of cerebral dis- 
ease, but also the muscles of the forehead, and the or- 
bicular muscles of the eyelids, are paralyzed ; hence the 
eye remains partly open, and even in sleep is not en- 
tirely closed, although the eyeball may turn upward, 
so that the pupil is covered. The lids are not closely 
applied to the eyeball ; hence, the tears do not find a 
ready entrance to the nasal duct, and the eye waters 
continually. 

There may also be a loss of taste in the anterior 
part of the tongue, and it has been claimed that the 
secretion of saliva is less on that side. 



PERIPHERAL PARALYSIS. 291 

Sometimes the velum palati is affected and hangs 
down loosely on the paralyzed side, and, when the mus- 
cles are brought into action in speaking, the action be- 
ing much greater on the sound side, the palate is drawn 
over toward that side. Sometimes the uvula has an ob- 
lique direction. Sense of hearing may be somewhat 
more acute on the paralyzed than on the opposite side. 

The tongue is protruded straight ; but sometimes, 
owing to the uneven position of the lips, the tongue 
appears to deviate. Careful observation of its position 
relative to the teeth will prevent any error. 

The reaction of degeneration is found in the mus- 
cles. The electrical reaction is of value as aiding in a 
formation of prognosis. In very mild cases the reac- 
tion of degeneration may not set in ; in cases of me- 
dium severity, the extreme form of the reaction of de- 
generation will not appear. 

It is possible, from certain peculiarities of the pa- 
ralysis, to diagnosticate very closely the seat of the le- 
sion. Erb has briefly stated the points of diagnosis, 
which may be summarized as follows : 

1. If there is complete paralysis of all the branches, 
if there is no disturbance of taste or hearing, and no 
paralysis of the palate, and if the electrical reaction is 
normal, the trunk of the facial is affected external to 
the Fallopian canal. 

2. Paralysis of all the external branches, with reac- 
tion of degeneration and absence of disturbance of 
taste, shows that the cause of the paralysis is within 
the canal and below the origin of the chorda tympani. 

3. With the same symptoms and disturbance of 
taste, the cause is between the origin of the chorda 
tympani and the ganglion geniculatum. If the hear- 
ing is abnormally acute, the lesion must be above the 
origin of the stapedius nerve ; otherwise below it. 

4. If, with the above symptoms, there is paralysis 
of the velum palati, the lesion is in the vicinity of the 
ganglion geniculatum. 



292 DISEASES OF THE PERIPHERAL NERVES. 

5. If all the above symptoms, except disturbance 
of taste, are present, and especially if there is also dull- 
ness of hearing and tinnitus, the lesion is at the base of 
the skull ; and this is rendered still more certain if 
other cranial nerves are affected. 

6. Erb states that if the same symptoms as in No. 
5 are present, except simple diminution of the electri- 
cal instability instead of reaction of degeneration, and 
especially if unusual or crossed reflex action be pres- 
ent, lesion of the facial nucleus may be diagnosticated ; 
and this is yet more certain if other cerebral nerves 
having their origin in this part are also paralyzed. 

After facial paralysis has continued for two or three 
months, it is not uncommon to have secondary contrac- 
tion set in, which delays recovery. The face, when at 
rest, may then have a more natural appearance ; but, 
when the mouth is moved, the difference in the two 
sides becomes apparent. Erb explains this condition 
as due to the changes that occur in muscles where there 
is the reaction of degeneration. 

Diagnosis. — The diagnosis of peripheral facial 
paralysis, from that caused by central lesion, is of 
much importance, especially for the comfort of the 
patient. 

The reaction of degeneration is one of the most im- 
portant aids ; in cases due to lesions of the brain, as a 
rule, only the lower branches of the nerve are affected, 
those that go to the eye and forehead acting normally. 
In cases of tumor or other disease within the skull, 
pressing upon the nerve just before it leaves the skull, 
there are general symptoms of tumor as well as those 
relating to other nerves, especially the auditory, which 
will aid materially in a diagnosis. 

Paralysis due to diseases of the ear must be diag- 
nosticated by the symptoms which are more particu- 
larly referable to the ear. The large majority of cases 
are due to the action of cold, so-called rheumatic pa- 
ralysis, and the history will not always aid in forming a 



PERIPHERAL PARALYSIS. 293 

diagnosis, as patients very often are not aware that they 
have been exposed. 

Prognosis. — In the lighter forms of rheumatic pa- 
ralysis the majority of cases get well. Some of the se- 
verer cases recover without special treatment ; yet, gen- 
erally, if there is no treatment, a certain amount of 
deformity remains which no subsequent treatment bene- 
fits. The best results can be obtained by the early use 
of appropriate measures. 

The prognosis in cases arising from disease of the 
ear depends entirely upon the nature of that disease 
and the amount of mischief which has been caused to 
the facial nerve. The prognosis in cases of disease 
within the cranium must be guided by the nature of 
that disease. 

Treatment. — It is necessary to say but very little 
in regard to the special treatment of facial paralysis. 
In the rheumatic form, painting over the neck just be- 
low the ear and behind the ear with tincture of iodine 
may be of some benefit. Electricity, the galvanic cur- 
rent by preference, interrupted at short intervals, is of 
most value. The internal use of remedies is of no value 
except in syphilitic cases. 

PARALYSIS OF THE BRACHIAL PLEXUS. 

There is nothing peculiar in the symptoms found in 
paralysis of the brachial plexus. A knowledge of the 
distribution of the nerves to the muscles will show 
what nerves are specially affected, and the resulting 
paralysis or deformity depends upon which muscles are 
affected. 

Among the most common causes are dislocation of 
the humerus, the head of the bone pressing upon the 
nerves in the axilla ; pressure of a crutch upon these 
same nerves ; pressure upon the radial nerve as it 
passes around the lower part of the humerus. This is 
most frequently found in patients who have fallen 
asleep upon their arm, especially if the arm rests upon 



294 DISEASES OF THE PERIPHERAL NERVES. 

any hard substance, and is more likely to occur when 
the sleep is very heavy, or from intoxication. Carry- 
ing burdens upon the arm, the hand resting upon the 
hip, may also be a cause. 

Among infants, paralysis of these nerves is some- 
times found as the result of delayed labor ; the press- 
ure upon the nerves in the neck, especially by forceps, 
may be a cause ; or, if the arm is drawn down in breech 
presentations, the nerves may be injured in the opera- 
tion. This is the so-called obstetric paralysis of in- 
fants. 

Other forms of peripheral paralysis require no spe- 
cial mention. 

PARALYSIS AFTER ACUTE DISEASES. 

Many acute diseases are sometimes accompanied 
with or followed by paralysis. Apparently the nature 
of the lesion which caused the paralysis is different in 
different cases. 

Among the diseases which are most frequently thus 
accompanied with local or more general paralysis may 
be mentioned small-pox, measles, scarlatina, typhoid 
fever, dysentery, sometimes diarrhoea, cholera, pneu- 
monia, and diphtheria. 

Generally, except in diphtheria, the paralysis oc- 
curs during the course of the disease, and may be 
found accompanying apparently light cases as weU as 
the more severe. 

Many times it seems as though an unusually high 
fever, perhaps of very short duration, were the exciting 
cause of the paralysis. 

Several times changes have been found in the spinal 
cord. This is especially true of small-pox. In other 
cases the paralysis seems to be of peripheral origin. 
The leo-s are more frequently attacked than the arms. 

The prognosis in almost all these cases is compara- 
tively favorable unless the spinal cord is the seat of the 
disease ; yet occasionally serious injury is done to the 



DIPHTHERITIC PARALYSIS. 295 

nerves or nerve-centers, and recovery is imperfect, the 
patient remaining more or less helpless during the rest 
of life, with atrophy of the paralyzed muscles. 

The treatment is such as has been already indicated 
in speaking of peripheral paralysis, or such as is re- 
quired in corresponding cases where the nerve-centers 
are affected. 

DIPHTHERITIC PARALYSIS. 

Diphtheritic paralysis requires rather more atten- 
tion than has been given to those arising from other 
acute diseases. It occurs after the primary disease has 
ceased. The patient is thought to have recovered 
health, and from eight to thirty days afterward the 
nervous disturbance is first noticed. The paralysis 
may appear after either severe or light cases of diph- 
theria. When it occurs soon after the primary disease, 
it is more gradual in its onset, and successive nerve- 
regions are affected one after the other. 

Diphtheria is most common between the ages of 
two and twelve. The paralysis following diphtheria is 
most common between the ages of ten and eighteen. 
It is impossible to foretell whether or not the patient 
will have paralysis following diphtheria. 

Symptoms. — The temperature often rises for a short 
time before the occurrence of the paralysis. In the ma- 
jority of cases there is first a slight change in the voice, 
which becomes nasal. The velum palati and the mus- 
cles of the larynx being paralyzed, there is regurgita- 
tion in swallowing liquids. When the attempt is made 
to swallow food, a portion passes down the wrong way 
into the larynx, causing choking and coughing. 

Sometimes disturbance of sight is the first symp- 
tom, there being dimness or partial loss of vision on 
account of paralysis of the muscles of accommodation. 
Strabismus may be caused by paralysis of the motor 
muscles of the eyeball. 

Frequently the legs lose the power of motion ; the 



296 DISEASES OF TEE PERIPHERAL NERVES. 

patient is unable to walk. Next in frequency the arms 
and hands are affected. Occasionally there is paralysis 
of the diaphragm, and less frequently of the heart. It 
is rare to have a case in which the paralysis is general. 
Usually one or two limbs are most affected, the others 
being only slightly affected, or escaping entirely, and 
in the majority of the cases the paralysis is limited to 
the velum palati and the larynx. 

The reaction of degeneration is very common in 
diphtheritic paralysis ; indeed, in the majority of 
cases the loss of power is due to a lesion of the ante- 
rior roots of the spinal nerves. It is supposed, how- 
ever, that the disturbance in the throat is due to a 
lesion of the nerve as it passes near the seat of the 
original disease. 

Sensation is only exceptionally disturbed. Very 
rarely, instead of loss of motor power, severe pain is 
felt in the course of certain nerves. 

Diagnosis. — The history of a previous sore throat 
or attack of diphtheria is sufficient to show the nature 
of the subsequent nerve-lesion. Without such his- 
tory it would be impossible to recognize the cause of 
the paralysis, though the nasal voice, the regurgitation 
of food, and the choking in swallowing, might lead 
one to suspect that there had been a diphtheria which 
had been overlooked. 

Prognosis. — The prospect is generally favorable, 
although occasionally patients die from an extension 
of the paralysis to the heart or muscles of respiration, 
and sometimes from inhalation's pneumonia, due to the 
passage of food into the bronchi. Except in such cases, 
the patients almost invariably recover under proper 
treatment. 

Treatment. — Where deglutition is seriously inter- 
fered with, the greatest care will be necessary in the 
treatment of the patient to avoid the passage of food 
into the trachea. 

Usually a soft solid can be swallowed better than 



i DIPHTHERITIC PARALYSIS. 297 

liquid food ; but in many cases it is necessary to omit 
feeding the patient by the mouth for a while, and in 
that case food should be given by enemata, in the way 
which has already been described. If necessary, a tube 
may be passed down the throat into the stomach, and 
the patient can be thus supported by artificial feeding. 

Paralysis of the limbs should be treated by keeping 
the limbs warm, by massage, by stimulating bathing, 
as with salt-water, warm rather than cold, and by the 
use of electricity. 

Iodide of iron is one of the most valuable tonics for 
such patients, and cod-liver oil, if it can be taken, is of 
great use. Otherwise, except as indicated by the pa- 
tient's general condition, no special treatment is neces- 
sary. 



CHAPTER XXV. 

SPASM. 

Nothnagel, Zur Lehre von klonische Krampf e. Virch. Arch. , 
xlix, pp. 267, 290.— Mitchell, S. W., On Functional Spasm. Am. 
Jour, of the Med. Sci., Oct., 1876, p. 321.— Mills, C. K, Spasms 
of the Muscles supplied by the Spinal Accessory Nerve. Am. Jour, 
of the Med. Sci., Oct., 1877, p. 425.— Remak, E., Zur Pathologie 
und Therapie localisirte Muskelkrampfe. Berl. kl. Wochenschr., 
May 23, 1881, p. 289.— Jones, C. H., Clinical Lecture on a Case 
of Spasmodic Disorders of the Lower Limbs. Brit. Med. Jour. , 
July 2, 1881, p. 41.— Robinson, E., Cases of Telegraphists' Cramp. 
Brit. Med. Jour., Nov. 4, 1882, p. 880.— Sinkler, Spinal Accessory 
Spasm. Med. News, April 19, 1884, p. 453.— Poore, G. V., An 
Analysis of Seventy-five Cases of Writers 1 Cramp. Med.-Chir. 
Trans., 61, 1878, p. 111. — Ibid., Writers' Cramp. Practitioner, 
1873.— Althaus, J., On Scriveners' Palsy. London, 1870.— Vigou- 
roux, R., Du traitement de la crampe des ecrivains par la me- 
thode de Wolff. Le prog, med., x, 1882, p. 37.— Thomsen, J., 
Tonische Krampfe in willkiirlich beweglichen Muskeln in Folge 
von ererbter psychischer Disposition. Arch. f. Psych., vi, 1876, 
p. 702. — Ballet et Marie, Spasme musculaire au debut des 
mouvements volontaires. Arch, denevrol., Jan., 1883, p. 1.— Rin- 
ger, Sydney, On the Nervous or Muscular Origin of Certain 
Spastic Conditions of the Voluntary Muscles. Lancet, Nov. 1, 
1884, p. 767 et seq. 

The convulsive actions included under the name 
spasm are of several varieties. 

Tremor is a very fine spasm of the muscles, which 
produces a trembling of the limbs, sometimes scarcely 
perceptible. It is rather a symptom of several morbid 
conditions than a disease of itself. 

Tonic spasm is a name given to the spasm when a 
muscle is contracted continuously without relaxation. 



SPASM. 299 

This, also, is rather a symptom than a disease, being 
found more especially in tetanus and spinal meningitis. 
It is sometimes difficult to recognize the difference be- 
tween a tonic spasm and what is called contracture of 
the muscles ; in fact, the latter may be looked upon in 
its earlier stages as simple tonic spasm, but later there 
is usually a change of structure in the muscles, and, 
the contracture becoming permanent and depending in 
large measure upon this change of structure, can no 
longer be called a tonic spasm. 

Clonic spasm is a name given to the convulsions 
which are attended with a rapid contraction and relax- 
ation of muscles. When these clonic spasms are ex- 
treme, and large groups of muscles are attacked, the 
name convulsions, or eclampsia, is used rather than 
clonic spasm, the latter name being reserved for the 
less severe and less extensive convulsions. 

In the following descriptions, clonic spasms will be 
chiefly considered. 

These are generally reflex in their origin, depending 
upon the irritation of some sensitive peripheral nerve, 
possibly far from the seat of the spasm. They many 
times, also, depend upon lesion of the central nervous 
system, in which case they are simply symptoms of 
the disease which gives rise to them. All such cases 
of spasm of central origin have been considered under 
diseases of the nerve-centers. 

It is not necessary to mention in detail spasms of all 
the various nerves. A few have such peculiar charac- 
teristics, and occur so frequently, as to be deserving of 
a separate mention. 

SPASM OF THE FACIAL NERVE. 

Irritation of the facial nerve in its course through 
the temporal bone, or at the base of the skull, may give 
rise to a spasm of the muscles supplied by it. Slight 
spasm of the muscles of the face is sometimes seen 
after facial paralysis. Irritation of the fifth nerve may, 



300 DISEASES OF THE PERIPHERAL FERVES. 

by reflex means, also produce spasm of the facial mus- 
cles. Very severe convulsive action of these muscles 
may accompany the pain in severe cases of trifacial 
neuralgia ; or, without pain, decayed teeth, inflamma- 
tion of the conjunctivae, abscesses about the face or in 
the cavity of the mouth, the influence of very bright 
light upon the eyes, as from the molten metal in a 
blast-furnace, may be causes. 

An irritation of distant organs, as the intestinal tract, 
or the uterus, seems sometimes to be the starting-point 
of facial spasm. 

This spasm is generally unilateral. All the mus- 
cles of one side of the face may be thrown into violent 
convulsions, producing the most ludicrous grimaces, 
lasting for a few seconds, relaxation being followed 
soon by another attack. 

The series of attacks may continue for several sec- 
onds or minutes, when there is a period of rest until 
the next attack occurs. Or, instead of general spasm, 
one or a few muscles may be affected. There may be 
slight twitching about the mouth or face. It may seem 
almost as if the patient had simply acquired a habit of 
which he might be readily broken. These spasms, how- 
ever, are very frequently involuntary and entirely be- 
yond the control of the will. 

Sometimes the orbicularis palpebrarum is exclu- 
sively affected ; then the patient closes the eye violent- 
ly, or simply winks rapidly. Occasionally the muscles 
of the forehead are also implicated. 

Blepharospasm is a tonic spasm of the eyelids, the 
contraction of the orbicular muscle persisting some- 
times for many minutes, or even hours. A bright light, 
an attempt to use the eyes for near vision, especially 
where great care is necessary in seeing small objects, as 
fine print, is sufficient to bring on an attack in those 
who are subject to this form of spasm. Sometimes a 
simple mental emotion will cause an attack. 

Pressure upon certain parts of the face may have 



TORTICOLLIS. 301 

the effect of relaxing this spasm, and occasionally such 
pressure will cause other facial spasms to cease. These 
points correspond to the painful points in facial neu- 
ralgia ; or such points may be found within the cavity 
of the mouth, or over the back of the neck, or even in 
regions supplied by the brachial plexus of nerves. Pa- 
tients frequently learn where these points are, and are 
able to cut short the spasm themselves. 

TORTICOLLIS, OR. WRY-NECK. 

Slight attacks of wry-neck may follow exposure to 
cold, and is spoken of as stiff-neck. This may also be 
the cause of more severe attacks ; it is said to arise also 
by reflex influence from irritation of the abdominal 
and pelvic viscera; in very many cases the cause is 
unknown. 

Symptoms. — The muscles affected in this form of 
spasm are those supplied by the spinal accessory nerve, 
the trapezius, and the sterno-cleido-mastoid. When 
the latter is contracted, the head is drawn over so that 
the occiput approaches the shoulder of the affected 
side ; the chin is turned toward the opposite side, and 
slightly upward. When the trapezius is affected, the 
head is drawn backward, and inclined toward the 
affected side. There is no rotation. Sometimes the 
shoulder is raised. The spasm usually begins so qui- 
etly and mildly that the motion at first is not notice- 
able. Soon the action of the muscle becomes stronger, 
and then the head is turned and jerked in a very dis- 
tressing manner. 

The spasms occur in separate paroxysms, lasting for 
a few seconds or minutes, frequently repeated, at times, 
with long intervals of rest. Sometimes other muscles 
are also affected besides those above mentioned. 

Patients learn to support the head by their hands, 
and forcibly to restrain the unpleasant action of the 
muscles. In violent cases, however, this manoeuvre is 
only partially successful. 



302 DISEASES OF TEE PERIPHERAL SERVES. 

Sleep may be interfered with. It may be difficult 
for the patient to take food. The mental influence of 
the affliction is such as to cause depression of spirits 
and diminish the appetite ; the patients may become 
thin and emaciated in consequence. Slight cases, how- 
ever, have no effect upon the general health. 

These muscles are occasionally affected with tonic 
spasm, in which case the head is firmly fixed in the po- 
sitions above mentioned. 

Diagnosis and Prognosis. — The diagnosis of these 
spasms is not difficult. The principal mistake would 
be, in cases of tonic spasm, to consider that the antago- 
nistic muscles were paralyzed. Spasm of other mus- 
cles of the neck may be mistaken for those already 
mentioned. When the splenius capitis is affected, the 
head is drawn backward and toward the affected side, 
the chin is somewhat depressed and directed toward 
the side of the spasm, and a hard ridge can be felt 
where the splenius appears beneath the anterior border 
of the trapezius. Spasm of the obliquus capitis infe- 
rior turns the head around its vertical axis without ele- 
vation of the chin or depression of the mastoid process. 
Spasm of the deep muscles of the neck draws the head 
strongly backward if bilateral, or toward the affected 
side when unilateral. (Ross.) 

In both facial spasm and torticollis the prognosis is 
very unfavorable. Very few cases recover. 

Treatment seems to be of very little value. In 
some cases electricity is successful. The galvanic cur- 
rent should be applied to the affected muscles, and the 
faradic current to their antagonists. 

Apparatus to produce permanent compression over 
the points of arrest has been tried, in some cases with 
success. 

Stretching of the spinal accessory, as it runs along 
the posterior edge of the sterno-mastoid, has been em- 
ployed with success in curing the spasm of torticollis. 

Division of muscles, or their tendons, has been em- 



SPASM. 303 

ployed in some cases with advantage, especially in the 
tonic form of spasm. Counter-irritation over the nerves 
supplying the affected muscles, by means of blisters or 
the actual cautery, may be of value. 

Of internal remedies, the most successful have been 
phosphate of zinc, sulphate of zinc, bromide of potas- 
sium, arsenic, and especially subcutaneous injection of 
atropia. 

Spasm of the Diaphragm, if tonic, may be the 
cause of death, and is always a serious affection. It 
rarely occurs independently of other disease. 

Clonic Spasm of the Diaphragm, or Hiccough, 
may be a light affection, with which every one is fa- 
miliar, or it may be a serious and obstinate symptom 
of disease of the viscera or of the nervous system. 

It is frequently associated with gastric, intestinal, 
and hepatic diseases, and in many cases is a symptom 
of bad omen, indicating the approaching fatal termi- 
nation. When existing independently of serious dis- 
ease, it is often obstinate, resisting treatment. 

The galvanic current applied along the course of the 
phrenic nerve, or, locally, over the insertions of the 
diaphragm ; the faradic current applied to the epigas- 
trium ; hot applications over the epigastrium — may be 
of benefit. Subcutaneous injections of atropia are 
especially useful, and those of morphia are of benefit. 

Thomsen's Disease.— A form of spasm has lately 
been described which is of more interest as a curiosity 
than practically as a disease. It consists of a stiffness 
and rigidity of the limbs, especially the legs, appear- 
ing only when an attempt is made to change the posi- 
tion, as in rising from a sitting posture, or commencing 
to walk after standing still. When the patient wishes 
to take a step, the leg is raised slowly, and with evident 
exertion, to an angle of about 120°. Standing very un- 
steadily on the other, the patient sets this down in 
nearly the same angle. If he then tries to raise the 



304 DISEASES OF THE PERIPHERAL NERVES. 

other leg, lie will fall, generally on the knee, rarely 
backward; or, if lie does not fall, he will walk un- 
steadily, the hips and knees bent at an angle of 120°, 
and remaining flexed while walking. After a few steps 
the gait improves, and soon the patient can walk natu- 
rally. Passive motion meets with resistance which is 
more marked the more rapid the motion. The arms 
and hands, or even face, are sometimes affected, and 
there is a similar difficulty in executing any movement 
as is found in the legs. 

The affected muscles are unnaturally large and hy- 
pertrophied ; there is no increase of fat ; no reaction of 
degeneration, though the electrical reaction may be less 
than normal. There is, as a rule, no pain, no cramp. 

The disease usually commences very early in life, 
perhaps is congenital, and in Thomsen's case seemed to 
be a family trait. 

Several authors locate the affection in the muscles. 

PROFESSIONAL CRAMP. 

Under this term may be included the difficulty which 
is found by writers and pianists, telegraphers, and oth- 
er persons in performing the various acts required by 
their profession, in consequence of spasm or weakness 
of the muscles engaged. 

^Etiology. — The cause of this affection is usually 
an excessive use of the hands and fingers, long con- 
tinued, in persons of a neurotic temperament, or who 
have been weakened by previous disease or debility. 
Occasionally injuries, sprains, blows upon the hand or 
arm, and exposure to cold, act as causes. 

Symptoms. — At first the difficulty experienced is 
very slight, consisting simply in a little awkwardness 
of motion or stiffness of the fingers ; sometimes a mere 
unpleasant sensation, hardly sufficient to be called pain, 
indicates the approach of the trouble. The arm and 
hand become more easily and quickly tired. Gradu- 
ally these symptoms become more marked ; the hand- 



PROFESSIONAL OR AMP. 305 

writing becomes decidedly poor ; spasms appear in dif- 
ferent muscles, and sometimes the thumb and fingers 
are so strongly flexed that the pen is pressed against 
the paper and broken ; at another time the extensor 
muscles are affected, and the fingers open, allowing the 
pen to drop. 

There is rarely decided pain, but a sense of weari- 
ness and exhaustion. Sometimes, however, the dis- 
comfort is very great, and extends up the arm as high 
as the shoulder. Occasionally pain is felt along the 
course of the nerve-trunks. 

When the disease is well advanced, the patient can 
write at most only one or two words — perhaps can not 
even sign his name. 

The arm and hand can be used for the ordinary pur- 
poses in life ; even laborious manual work can be per- 
formed without difficulty ; but, as soon as the patient 
undertakes to employ the fingers for any delicate opera- 
tion, as writing, playing the piano, or sewing or knit- 
ting, the symptoms immediately reappear. 

The electrical reaction of the muscles is increased in 
the early stages of the disease, and it is only after a 
long time that any diminution of the reaction can be 
recognized. 

Persons affected with this disease may learn to write 
with the left hand : but in so doing should be careful 
not to overtax that hand ; if they do, the same symp- 
toms may appear on the left side ; if careful, they may 
be able to use the left hand without difficulty. 

Views differ somewhat as to the nature of this af- 
fection. Althaus looks upon it as due to fatigue and 
functional irritability of the co-ordinative centers in the 
upper portion of the spinal axis. Ross is inclined to 
look upon the main lesion as situated either in the gan- 
glion-cells of the spinal cord, or the nerves when the 
electrical reactions are diminished ; in the cortex or 
conducting-path above the spinal level when the elec- 
trical reactions are increased. Others consider that the 

20 



306 DISEASES OF THE PERIPHERAL NERVES. 

seat of the disease is in the muscles or the terminal 
nerve-apparatus. 

The diagnosis presents no special difficulties. The 
prognosis is far from favorable except in very recent 
cases. 

Treatment. — Entire rest from the cause of the dis- 
ease is absolutely necessary for recovery. This rest 
must continue for many months — six at least. 

The galvanic current frequently gives good results. 
It is applied in various ways by different observers. 
One pole should be placed on the neck over the spinal 
column, and the other applied over the affected mus- 
cles and nerves of the arm. 

Erb recommends the application of the galvanic cur- 
rent to the head (transversely, longitudinally, oblique- 
ly) ; also to the cervical sympathetic. 

Showering the arm with hot or cold water some- 
times gives relief. 

Wolff has obtained excellent results by the combi- 
nation of gymnastics and massage. He uses both act- 
ive and passive motion, exercising the affected mus- 
cles until they are fatigued. The massage is applied to 
the fingers, hand, wrist, and arm. He uses percussion 
with the ulnar border of the hand over the affected 
muscles. His method has attracted much attention, 
and several articles have appeared in recent medical 
journals describing the process. 






CHAPTER XXVI. 

DISEASES OF THE SYMPATHETIC. 

Wright, H. G., Headaches : their Causes and their Cure. 
London, I860.— Smith, A. A., The Therapeutics of Headache. 
Med. Record, Aug. 5, 1876, p. 503.— Woakes, E., The ^Etiology 
and Treatment of Occipital Headache. Practitioner, April, 1878, 
p. 263. — Warner, F., Recurrent Headache in Children. Brit. 
Med. Jour., Dec, 6, 1879, p. 889 ; Brain, Oct., 1880, p. 309.— 
Day, W. H, Headaches : their Nature, Causes, and Treatment. 
Philadelphia, 1883. 

Liveing, E., On Migraine. London, 1873.— Allbutt, On Mi- 
graine. Practitioner, x, 1873, p. 25— Seguin, E. C, A Contribu- 
tion to the Therapeutics of Migraine. N. Y. Med. Rec, Dec. 8, 
1877. — Spender, J. K., The Treatment of Migraine. Lancet, June 
14, 1884, p. 1144.— Hughes, C. H., Migraine. Alienist and Neu- 
rologist, April, 1884, p. 277.— Brunton, T. L., On the Pathology 
and Treatment of some Forms of Headache. St. Barthol. Hosp. 
Rep., 1883, p. 329.— Jewell, J. S., The Nature and Treatment of 
Headaches. Jour, of Nervous and Ment. Diseases, Jan. -April, 
1881. 

CEPHALALGIA.— HEADACHE. 

It is not necessary to consider headaches occurring 
as one of many symptoms in various constitutional and 
inflammatory diseases, nor as an attendant upon or- 
ganic cerebral diseases. Even when not thus associ- 
ated, it is frequently only one of several symptoms, 
but the one which gives most distress, and requiring 
relief. 

Whatever seriously lowers the tone of the nervous 
system or the general health may be an efficient cause. 
Neurasthenic patients usually suffer from some form of 
headache, most frequently of a dull or heavy kind, 
which is almost continuous. 



308 DISEASES OF THE SYMPATHETIC. 

Defective sanitary conditions, bad drainage, or poor 
ventilation, may cause the disturbance ; frequently a 
morning headache may be traced to sleeping in an illy- 
ventilated room. 

Anaemia and hyperemia of the brain are said to 
cause headache. I doubt whether the variety of pain 
will help to distinguish between these two conditions : 
the diagnosis must be made from other symptoms or 
conditions. It is to be kept in mind that an anremic 
patient may have a sudden flow of blood to the head, 
giving rise to headache of the congestive variety. 

Alcohol, tobacco, various deleterious gases, as sul- 
phureted hydrogen, carbonic oxide, or the gas used for 
lighting, may cause headache ; chronic lead-poisoning 
is another cause. 

Headache is sometimes the only symptom of tertiary 
syphilis ; it is frequent in Bright's disease, and may be 
the first sign of trouble. There is also, apparently, 
a connection between headache and rheumatism and 
gout. 

A very large class of cases are reflex in origin, de- 
pending upon disease or derangement in distant or- 
gans ; the digestive and urino-genital organs are most 
frequently the seat of such disturbance. 

Differences in the refractive power of the eyes may 
be the exciting cause of headache, and in every doubt- 
ful case an oculist should examine the eyes. 

A careful examination of all the possible derange- 
ments is necessary to form a correct diagnosis ; but with 
care there is usually not much trouble in arriving at a 
reasonable conclusion : in some cases, however, it will 
not be possible to discover the cause or nature of the 
affection. 

Headache is rare in early childhood, and, when pres- 
ent, may be of serious import ; it ought to lead to a 
watchful care lest it should be the forerunner of some 
serious disease. About the period of second dentition, 
and until puberty, headache may be more common, 



HEADACHE. 309 

and is sometimes severe and continuous, with remis- 
sions, but few intermissions. It is not then of a sharp, 
piercing character, but rather heavy and .dull, increased 
by mental exertion and confinement. 

In old age it is not common, and is of more impor- 
tance than in middle life. 

Tkeatment. — It may be necessary to change the 
patient's mode of life or residence. If there is any 
unfavorable influence about the house, it should be 
remedied, or, if that is not possible, the patient should 
change his residence. 

Too severe mental application, whether in study or 
in business, must be moderated, and this is not always 
easy to accomplish. Sedentary habits must be broken 
in upon, exercise out of doors must be insisted upon, 
and late hours, whether for business or amusement, 
must give place to early retiring. High heels and tight 
lacing, and insufficient clothing, need to be looked 
after, even if the contest with what is thought fashion- 
able seems well-nigh hopeless. 

The diet should be regulated ; the high and gener- 
ous liver may expect to suffer until he can reduce his 
diet. An occasional saline cathartic may give tempo- 
rary relief; or, if there is a gouty tendency, colchi- 
cum may be used ; but more than that is needed, and 
while the patient persists in indulgence not much will 
be gained. In gouty cases, citrate of lithia, five grains 
or more three or four times a day, promises well. 

Alcohol and tobacco should, of course, be given up ; 
if there is any suspicion of lead-poisoning, iodide of 
potassium should be given to eliminate the poison. 

Dyspepsia, or other affections which may act as 
causes, must be treated by appropriate means if pos- 
sible. 

During the attack, in cases of excessive blood-sup- 
ply, counter-irritation to the back of the neck, cold to 
the neck, or an ice-bag to the lower part of the spine, 
ergotin in three-grain doses, bromide of potassium in 



310 DISEASES OF THE SYMPATHETIC. 

thirty to sixty grains ; if the pain is severe, wet cups to 
the back of the neck, or leeches behind the ear — may 
be tried. 

In nervous headaches, or those caused by exhaus- 
tion or overwork, citrate of caffein, two to five grains, 
is frequently sufficient for its removal; yet the caffein 
sometimes causes nausea. Aromatic spirit of ammonia 
and sweet spirit of niter are excellent remedies ; a tea- 
spoonful of each can be given, and repeated in one or 
two hours if necessary. Valerianate of ammonia, spir- 
it of lavender, camphor, or asafoetida, may serve when 
other remedies fail. Hot water to the head is usually 
more grateful than cold. 

Between the attacks, ergotin, in tendency to a con- 
gestive condition, with care as to habits. In other 
cases, the various tonics, cod-liver oil, and good feed- 
ing. Extract cannabis Indica, in third to half-grain 
doses three times a day, has proved very useful, not 
merely in migraine, as advised by Seguin, but in more 
common forms. The drug should be continued several 
weeks. 

Iodide of potassium seems to be useful in other 
cases than where there is a rheumatic or syphilitic 
taint. Dr. Haley found that it relieved a dull, heavy 
headache over the brows accompanied by languor, chil- 
liness, and feeling of discomfort. He gave it in two- 
grain doses, in half a wine-glass of water, to be sipped 
slowly. 

Massage to the head will often relieve the pain in a 
few minutes ; in chronic cases, the massage should be 
given for a long time, and may be general. 

The galvanic current, passed from the forehead to 
the back of the neck, or transversely, may be tried, or 
the faradic current from forehead to neck. It is better 
to use the operator's hand as the electrode on the fore- 
head, the battery-electrode being held in his other 
hand. The hand fits the shape of the forehead better 
than the common metallic electrodes, and the operator 



SICK HEADACHE. 311 

can thus judge more correctly as to the strength of the 
current, which needs to be very mild. 

MEGRIM.— SICK HEADACHE.— MIGRAINE. 

Megrim, or sick headache, is a paroxysmal head- 
ache, usually limited to one side, frequently attended 
with nausea and vomiting ; the intervals between the 
attacks are usually free of pain. 

.ZEtiology. — Heredity is even more evident in this 
than in many neuroses. Frequently it occurs in several 
successive generations in the same family. 

Women are slightly more liable than men ; Liveing 
says as 5 to 4, Eulenburg says as 5 to 1. 

The first attack occurs most frequently before ten, 
or at puberty. It rarely begins after twenty-five. 

Certain influences, as imprudence in diet, exhaust- 
ing exertions, excitement, late hours, noise and confu- 
sion, will give rise to an attack : and these may occur 
more frequently at the catamenial period ; but why it is 
so we do not know. 

Symptoms.— As in other "explosive" neuroses, the 
patient is usually free from pain, and in the enjoyment 
of good health, between the attacks. Sometimes the 
paroxysm is preceded by a warning ; perhaps an un- 
usual buoyancy of feeling and sense of exhilaration are 
noticed on the preceding day, and the patient knows 
he is about to be sick because he feels so well. Or, 
again, an indisposition begins the day before, and gives 
notice of the coming storm. 

In almost every case, pain is the most prominent 
symptom. The pain is felt on waking ; usually it is 
mild at first, but increases as the day advances until it 
reaches its greatest intensity. Sometimes the pain be- 
gins later in the day, and occasionally it is absent 
throughout the attack, the other symptoms alone ap- 
pearing. The pain varies much in character and se- 
verity in different attacks, even in the same person. It 
is usually unilateral, the side affected varying, at one 



312 DISEASES OF TEE SYMPATHETIC. 

time the left, and the next time, perhaps, the right side 
suffering. Sometimes it is bilateral, though then one 
side may suffer the more severely. At the beginning 
of the attack the pain is limited to one region, gener- 
ally the forehead or the temple ; as it becomes worse, 
it spreads over the whole side of the head. The pain 
continues throughout the paroxysm, six or eight to 
twenty-four hours, rarely longer, though a sense of 
heaviness or depression may remain for a while longer. 
There is general tenderness of the scalp over the region 
affected, rather than any special tender points. 

Almost from the commencement of the pain there is 
a loss of desire for food, or absolute loathing of it. As 
the headache continues, this feeling changes to nausea, 
and at length vomiting sets in. One severe spell of 
vomiting may close the attack, and the pain cease, 
drowsiness or sleep following or not. Generally, how- 
ever, more than one fit of retching and vomiting occurs, 
and the prostration is correspondingly severe, as the 
pallor, sweating and weakness show. 

The drowsiness or heavy sleep which sometimes 
follows the vomiting may be in part the result of the 
exhaustion caused by the pain and the vomiting. It 
is not like the quiet, natural sleep which sometimes 
closes the attack ; it rather resembles the stupor follow- 
ing an epileptic fit. 

Other symptoms are less common than the pain and 
nausea. Visual disturbances are next in frequency, 
and, when present, generally appear before the pain. 
They consist in partial or total loss of sight, and in va- 
rious luminous appearances, of greater or less brilliancy, 
and sometimes colored. The loss of vision is sometimes 
central and sometimes lateral ; there may be true lat- 
eral hemianopsia. The luminous phenomena may con- 
sist simply in the perception of a bright light, without 
definite form, or there may be zigzag lines of light, 
sometimes colored, resembling fortifications. A small 
point of light is first seen, which gradually expands, 



SICK HEADACHE. 313 

increasing in size, assuming the above zigzag form, un- 
til it extends beyond the field of vision and disappears. 
Meanwhile, a new spot appears, and goes through the 
same changes ; the lines of light have tremulous mo- 
tion. 

Disturbances of common sensation, anaesthesia, and 
sometimes of the special senses, on the same side with 
the headache, are less frequent. When the numbness 
is on the right side, there may be with it one of the 
forms of aphasia. 

In severe cases it is impossible for the patient to 
apply himself mentally ; but sometimes more than this 
mental disturbance is noticed, though not to any serious 
extent, even during the seizures. 

Pathogenesis. — It is often assumed by the patient 
that the attacks of migraine are due to gastric disturb- 
ance ; as the nausea and vomiting are so frequent, this 
is not strange, and too often the physician falls in with 
this view. While imprudence in diet may sometimes 
be the exciting cause of an attack, it is only incident- 
ally so ; other causes are equally as effective. The phe- 
nomena are all referable to cerebral influence ; the 
nausea is from the encephalon, not from the stomach. 

Any one interested in the different theories will 
find them fully discussed by Liveing. 

There seem to be two conditions of the cerebral 
circulation during the attacks ; in some the vessels seem 
to be in a state of spasm, contracted ; in others dilated. 
Liveing refers the attacks to the explosive tendency to 
be found in the nervous system even in health. 

There is usually no anatomical change possible, as 
the attacks are so fugitive. Occasionally certain of the 
sensory disturbances, as numbness or visual change, 
are more permanent, so that a slight structural change 
in the brain might be possible. A change in the circu- 
lation, and, in the above rare cases, in the structure of 
the posterior part of the inner capsule and adjoining 
portion of the optic thalamus, would explain the symp- 



314 DISEASES OF THE SYMPATHETIC. 

toms, except, perhaps, the headache and nausea. Pro- 
visionally, we may imagine this to be the seat of the 
change, though our actual knowledge in this regard is 
very slight. 

There is a resemblance between the attacks of mi- 
graine and those of epilepsy, which it is not necessary 
to specify minutely. A few cases have been observed 
in which migraine in early life was later replaced by 
epilepsy. 

Peog^osis. — The prospect is very slight of com- 
plete immunity from the attacks during early life ; 
with advancing years the frequency of the paroxysms 
diminishes, and finally the patient is free. Yet much 
benefit may be derived from treatment in diminishing 
the severity and frequency of the attacks. 

Teeatment. — Such hygienic measures should be 
adopted as will most effectually remove the exciting 
causes ; over-exertion of the brain, neglect of proper 
exercise and out-door life, late hours, excitement — such 
influences can be avoided by sufficient self-denial on 
the part of the patient except in the cases where the 
struggle for the necessaries of life demand the sacrifice. 
Much can be done, also, by means already alluded to, 
to increase the strength and vigor of the nervous sys- 
tem. 

During the attack the patient will instinctively take 
the precautions as to rest and posture which are most 
favorable. The friends may, however, be too fussy. 
Quiet, i. e., freedom from noise, motion, jarring, and 
from conversation ; exclusion of light ; coolness in the 
atmosphere of the room, not chilliness ; abstinence from 
food — these conditions may be obtained by the aid of 
friends, or officious friends may render it impossible 
for the patient to have them. 

Drugs taken early in the attack may diminish its 
severity. Sometimes a large dose of quinine, ten to 
twenty grains, is of benefit ; caffein, or citrate of caf- 
fein, in two- to five-grain doses, is more effectual ; prep- 






SICK HEADACHE. 315 

arations of guarana have an effect similar to caffein. 
In cases of paralysis of the vaso- motor constrictor 
nerves, ergot is of value ; where there is spasm of those 
nerves, the inhalation of nitrite of amyl proves of value, 
but it may be necessary to repeat it several times at 
short intervals ; one to three drops may be inhaled ; 
when a patient's peculiarities and susceptibility to the 
drug are known, larger doses may be used ; belladonna 
or atropia may be of use in the same class of cases ; 
nitro-glycerine, or glonoin, as it is also called, has been 
recommended, one drop of the one-per-cent solution be- 
ing used in water, but its value is doubtful. Chloride 
of ammonium, twenty to forty grains, may diminish the 
severity of the pain. Copious draughts of hot water 
have been of value with some patients. After the nau- 
sea has become marked, internal remedies are likely to 
increase it, and add to the distress by causing vomiting ; 
though, in rare cases, the emesis relieves the pain and 
shortens the attack. 

Several remedies have a value in diminishing the 
frequency of the attacks. Extract of cannabis Indica 
in one-third- to one-half-grain doses three times a day 
is very valuable, but it must be continued several 
weeks. Valerianate of zinc, three grains three times a 
day, is also useful ; and in larger doses, five or six 
grains every three hours, it may shorten the attack. 

Liveing found iodide of potassium, five grains three 
times a day, of advantage, and he also recommends 
bromide of potassium. It should be given in ten- to 
twenty -grain doses three times a day for several 
months. 

The galvanic current may be used with advantage. 
In cases where the vessels are contracted, the negative 
pole should be held in the hand, or on the back of the 
neck, while the positive pole is placed over the cervi- 
cal sympathetic without interruptions. In cases with 
paralysis of the constrictor vaso-motor nerves, Erb ad- 
vises the cathode over the sympathetic, and that the 



316 DISEASES OF TEE SYMPATHETIC. 

current should be repeatedly opened and closed, avoid- 
ing, however, too strong irritation. 

The faradic current, used as advised for simple 
headache, sometimes gives relief. 

Many times these applications can not be made dur- 
ing the attack, as the pain is increased by the simple 
manipulations necessary, and not relieved by the elec- 
tricity. 

Between the attacks, general faradization or galvani- 
zation may be of great service, as in other cases of di- 
minished nervous power, in restoring the system to a 
normal condition. 

Massage would rarely be of value during the attack, 
but in its incipient stage, and between the attacks, may 
be of great benefit. 

GRAVES'S DISEASE (Exophthalmic Goitre). 

Eulenburg und Guttmann, Die Basedow'sche Krankheit. 
Arch.f. Psych., i, 1868, p. 430.— Wilks, S., Exophthalmic Goi- 
tre. Guy's Hosp. Rep., 1870, p. 7.— Russell, J., Clinical Illus- 
trations of Graves's Disease. Med. Times and Gaz., Sept. 2, 1876 
et seq. — Chvostek, Die Therapie der Basedow'sche Krankheit. 
Zeitschr. f. Therapie, No. 8, 1883. 

Exophthalmic goitre is an affection attended with 
three prominent symptoms — palpitation, goitre, and 
exophthalmos. 

Symptoms. — The disease usually begins by a nerv- 
ous irritability and change of character, feeling of 
fullness in the head and eyes and neck, and palpita- 
tion. In most cases the palpitation is spoken of as the 
first symptom, perhaps because it first attracts atten- 
tion. The heart's action rises to 100 or 150 ; but there 
are no signs of organic disease of the heart. 

The projection of the eye is usually attended with a 
diminution in the motion of the upper lid, so that, if 
the eyeball is rolled upward, the lid does not move in 
harmony therewith. 

Sight is not affected, and accommodation is not dis- 



GRAVES'S DISEASE. 317 

turbed. The ophthalmoscope generally shows nothing 
abnormal, though optic neuritis has been seen. 

The thyroid gland slowly increases in size until it 
becomes quite prominent ; even the middle lobe may 
be enlarged. In consequence of this enlargement, the 
voice may be somewhat changed in character, and res- 
piration may be disturbed. 

Various general symptoms may be associated with 
the above. The appetite suffers; diarrhoea sometimes 
sets in ; there may be extreme emaciation ; anaemia is 
not uncommon. 

Among women, the catamenia may cease, or there 
may be dysmenorrhcea. There is sometimes unilateral 
sweating. 

Sometimes one of the three prominent symptoms 
may be absent. 

As a rule, the symptoms are very slightly marked at 
first, but gradually increase in severity, the disease be- 
ing chronic in its course. Occasionally an acute case 
appears, in which all the symptoms are rapidly devel- 
oped. 

Pathology. — The pathology of this disease is by 
no means easy to explain. Panas is inclined to think 
that the disease depends upon a disturbance of the 
medullary oblongata, an irritation which would excite 
the sympathetic fibers passing to the heart, and the 
vaso-dilator nerves would explain the symptoms. Or, 
on the contrary, a paralysis of the inhibitory nerves, 
and of the vaso-constrictures. Panas is inclined to 
the belief that the latter is the correct explanation. 

Anatomical changes have been found several times 
in the cervical sympathetic, especially in the lower 
ganglion. 

Prognosis. — Prognosis is not very favorable, though 
several cases of recovery have been reported. 

Treatment.— Digitalis has but little influence in 
moderating the rapidity of the heart's action. Bella- 
donna has sometimes been of use. Quinine and iron 



318 DISEASES OF THE SYMPATHETIC. 

have also proved serviceable. The best results have been 
obtained by Chvostek from the use of electricity. He 
used the ascending galvanic current to the cervical sym- 
pathetic, and on each side, stabile, one minute ; to the 
spinal cord the positive pole on the fifth dorsal, the 
negative on the cervical vertebrae ; he also passed a cur- 
rent transversely through the head from one mastoid 
process to the other ; or in some cases applied it to the 
temples. The application was about one minute in 
each place. He used a very weak current, which caused 
no sense of heat, and applied it daily. 

Meyer and Leube have both obtained good results 
from galvanism. 

ANGINA PECTORIS. 

See, G., De l'angine de poitrine. France med., 1876, p. 197 
et seq. — Balfour, G-. W., Upon Paroxysmal Angina Pectoris. 
Edinburgh Med. Jour., March, 1881, p. 769.— Huchard, H. Le 
concours med., No. 6, 1884. 

Angina pectoris is a disease characterized by pain- 
ful paroxysms, the pain being situated in the neighbor- 
hood of the heart, and radiating thence to the left side 
of the chest and left arm. The attacks are accompa- 
nied with great anxiety and a sensation of impending 
dissolution. 

JEtiology. — The disease attacks males by prefer- 
ence, and occurs most frequently after the age of forty. 
It is uncertain whether heredity plays any part in the 
aetiology of this disease. Gout, rheumatism, and alco- 
holism are supposed to be important as causes. Ex- 
cessive tobacco-smoking is also spoken of as predispos- 
ing to the disease. Many cases of angina pectoris are 
found in persons who have organic diseases of the 
heart, and these are naturally looked upon as giving rise 
to the pain. Especially is this true in regard to changes 
in the coronary arteries, or such changes at the com- 
mencement of the aorta as are likely to interfere with 



ANGINA PECTORIS. 319 

the circulation of the blood through the substance of 
the heart. 

As directly exciting to the attacks may be men- 
tioned exposure to cold, unusual mental emotions and 
bodily exertion, especially walking against a strong 
wind, or walking rapidly up hill, or ascending a flight 
of steps rapidly. Yet many cases occur in which there 
has been no special exciting cause, as is particularly 
true of those attacks which occur during sleep. 

Pathological Anatomy. — The anatomical changes 
found are such as belong to the organic diseases of the 
heart, which may be supposed to exert an influence as 
predisposing causes. Otherwise than these changes, 
which need no special description, there is no anatomi- 
cal lesion discoverable. 

Symptoms. — The prominent symptom of this dis- 
ease is pain, which is situated usually along the left 
border of the sternum, and more especially near the 
apex of the heart. Thence the pain may radiate over 
the whole chest, may descend along the left arm, rarely 
going below the elbow. The pain is not so sharp and 
acute as some other species of neuralgia, but it is at- 
tended with such anxiety and distress, such a sense of 
danger to life, that it is much less bearable than almost 
any other variety of pain. 

During the attack the pulse is often increased in 
rapidity, but is rarely irregular unless there is organic 
cardiac disease. The respiration is sometimes unaf- 
fected, though very often the patient instinctively holds 
his breath, and remains immovable, supporting himself 
by his arms, as if afraid even to breathe. Each attack 
of severe pain is usually of but short duration ; but 
they may succeed one another rapidly, and the duration 
of the whole attack is very variable, sometimes extending 
over days, though when so long there are generally pe- 
riods of remission almost amounting to intermission. 

When the attack has finally ceased, the patient is 
usually free from pain until the recurrence of the next, 



320 DISEASES OF THE SYMPATHETIC. 

which may not be for many months ; but, as the at- 
tacks recur, their frequency becomes greater, until the 
intervals between are very short. 

Prognosis. — When the disease depends upon an 
organic change of the heart, death usually follows after 
a longer or shorter interval. Where there is no organic 
change of the heart, the patient may recover, and live 
long without a recurrence of the disease. 

The nature of the disease is but imperfectly known. 
It is generally considered as belonging to the neural- 
gias. Some cases are referable to gout or rheumatism ; 
some are probably due to fatty degeneration of the 
walls of the heart. Some again, perhaps, depend upon 
an imperfect supply of blood to the heart, in conse- 
quence of disease of its nutrient arteries. It has also 
been referred to a neuritis of the cardiac nerves. As 
has been remarked : "It is very difficult to choose an 
opinion out of the midst of this labyrinth of explana- 
tions, which contradict each other and destroy each 
other." 

Diagnosis. — The chief danger of mistake lies rather 
in considering a simple neuralgia, affecting the inter- 
costal nerves, as angina pectoris. 

The character of the pain is different, the anxiety 
and distress attending it are much less in intercostal 
neuralgia, or are entirely wanting. 

Embolism of the pulmonary artery is attended with 
much greater dyspnoea, and the circumstances asso- 
ciated with it will assist to a diagnosis. 

It is of primary importance to learn whether the 
pain is associated with organic disease of the heart. 
To do this, it would be necessary to examine the heart 
between paroxysms. And even a careful physical ex- 
amination may not settle the question without doubt. 

Treatment. — Eulenburg says : " The remedies are 
many, the cures few." During the paroxysm it is 
most important to relieve the pain and distress. 

Nitrite of amyl will sometimes cut the attack short. 



ANGINA PECTORIS, 321 

Five or six drops on a handkerchief, inhaled by the pa- 
tient, repeated if necessary, may suffice to relieve the 
paroxysm. 

The subcutaneous injection of morphia, with a small 
amount of atropia, will often give relief. With other 
patients, the most speedy relief is experienced from 
the application of ice immediately over the heart. M- 
tro-glycerine (glonoin), in the dose of one or two drops 
of the one-per-cent solution, has been recommended, 
and has, in some cases, proved very efficacious, not only 
in relieving the pain of the attack, but in warding off a 
recurrence. 

Acomtia, by preference Duquesnil's, in dose of from 
rro- to 2-fo- °f a grain, repeated, if necessary, every hour 
or two hours, until there is tingling of the lips, or 
tongue, or fingers, will often give relief, but is less 
rapid in its action than the remedies previously men- 
tioned. The benefit derived from this drug is, however, 
of longer duration. Tincture of aconite-root may be 
used instead. 

Between the attacks means should be taken to di- 
minish the danger of a recurrence. If there is any 
gout or rheumatic tendency, appropriate remedies 
should be used. In other cases the general health 
should be maintained, the patient cautioned against 
over-exertion of any kind, and, as many of these pa- 
tients are run down in general health and overtaxed, 
a large proportion of rest is absolutely necessary. 
Smoking should be given up. 

Among the drugs which may be used with the pros- 
pect of greatest benefit is arsenic. Besides this, prepa- 
rations of iron and zinc may be used. Nitrate of silver 
has been recommended. Digitalis, combined with the 
arsenic, is also mentioned as valuable. 
21 



322 DISEASES OF THE SYMPATHETIC. 



SYMMETRICAL GANGRENE. 

Raynaud, M. , Nouvelles recherches sur la nature et le traite- 
ment de l'asphyxie locale des extrernites. Arch. gen. de med., 
1874, Jan., p. 1 ; Feb., p. 189.— Warren, J. C, Symmetrical Gan- 
grene of the Extremities. Boston Med. and Surg. Jour., Jan. 16, 
1879, p. 76. — Weiss, M., Ueber sogenannte symmetrische Gan- 
gran. Zeitschr. f. Heilk., iii, 1882, p. 233. 

The causes of this peculiar affection are not known. 
The disease consists in a disturbance of the circulation, 
especially in the extremities, probably an affection of 
the vaso-motor nerves, by which the supply of blood is 
cut off, and hence the nutrition suffers ; and, when car- 
ried to an extreme, gangrene sets in, and the affected 
parts slough off. Fingers and toes are the most fre- 
quently affected ; but limited spots on the body, and 
even the face, may suffer. The disease is almost al- 
ways symmetrical, and is paroxysmal. 

In many patients there is a prodromic period of un- 
rest, with change of character. The patient becomes 
peevish, fretful, surly, withdraws within himself, and 
avoids contact with those whom he formerly sought, 
even his own children. He sighs, and frequently sheds 
tears. Sleep is restless, broken by dreams. Appetite 
poor, digestion difficult, and the slightest excess is fol- 
lowed by severe gastric crises, similar to those seen in 
ataxia. Hearing, sight, and taste may be diminished. 

A disagreeable sensation is felt in the limbs ; the 
circulation is sluggish ; the surface becomes cyanotic, 
perhaps almost black ; generally, severe pain, of a neu- 
ralgic character, sets in, which is without intermission, 
almost without remission. The affected parts are an- 
aesthetic, and this may cause the gait to assume an 
ataxic character. 

After reaching this stage, the symptoms may sub- 
side and the normal condition of the parts return. 
Otherwise, the disturbance of nutrition increases, and 
there is gangrene affecting the fingers and toes, or su- 



SYMMETRICAL GANGRENE. 323 

perficial spots of the skin, and after fonr or five days 
the dried epidermis falls off, leaving a superficial ulcer, 
which heals slowly. If a whole phalanx of finger or 
toe is affected, this drops off, and the stump cicatrizes 
slowly. 

There is no fever attending the above phenomena. 
The heart is unaffected ; the pulse is not disturbed, even 
in the arteries near the cyanotic parts. The tempera- 
ture is lowered in the affected limbs. Occasionally 
there is no pain. 

Raynaud found the circulation of the fundus of the 
eyes affected, arteries contracted, and venous pulsation ; 
in one case he found these changes between the attacks ; 
in another case at the same time with the attacks. 

The diagnosis is not difficult when the whole series 
of symptoms is before one ; but at the beginning there 
might be some doubt as to the nature of the affection, 
and it would be excusable to suspect locomotor ataxia, 
or disease of the spinal membrane. 

Teeatment. — Warmth and rest are indicated ; some 
of the symptoms might be relieved by gentle massage. 

Raynaud obtained excellent results from the use of 
the galvanic current applied over the spinal column. 
He used from twenty-five to thirty cells, the positive 
pole over the fifth cervical vertebra, the negative pole 
over the sacrum. After a short time he slid the nega- 
tive pole up to the eighth dorsal vertebra. The appli- 
cation was continued ten to fifteen minutes daily. The 
circulation became more rapid ; abundant sweat ap- 
peared ; the hands became moist ; in some cases head- 
ache followed the application, and then it was neces- 
sary to reduce the number of cells. He also applied 
the positive pole over the nerves in the upper part of 
the limb, and the negative pole over the affected sur- 
face. He was able to use in this way from thirty to 
sixty cells. As improvement appeared, sensation be- 
came more acute, and it was necessary to reduce the 
number of cells. 



324 DISEASES OF THE SYMPATHETIC. 



UNILATERAL FACIAL ATROPHY. 

Guttmann, P., Ueber einseitige Gesiclitsatrophie. Arch. f. 
Psych., i, 1868, p. 173.— Bannister, H. M., Progressive Facial 
Hemiatrophy. Jour, of Nervous and Mental Diseases, Oct., 1876, 
p. 539.— Hammond, Wm. A. Ibid., April, 1S80, p. 250.— Flashar, 
Ein Fall von bilateraler neurotischer Gesiclitsatrophie. Berl. hi. 
Woch., Aug. 2, 1880, p. 441.— Wette, H. CM. f. d. m. Wissen., 
July 8, 1882, p. 491.— Mendel. Berlin. Jcl. Wochenschr., Sept. 17, 
1883, p. 588.— Jessop and Browne. St. Barthol. Hosp. Rep., xviii, 
1882. — Wolff, Ueber doppelseitige fortschreit. Gesiclitsatrophie. 
Virch. Arch., 94, 1883, p. 393. 

The cause of unilateral atrophy of trie face is not 
certain ; more cases have been noticed in women than 
in men ; frequently injuries have preceded the atro- 
phy. 

Symptoms. — Preceding the change in the tissues of 
the face there may be a prodromic period, during 
which there is pain in the face and head, with perhaps 
hyperesthesia. Bannister noticed absence of perspira- 
tion on the affected side of the face, without pain. 

Before the atrophy, there is usually a whitish dis- 
coloration of the skin at the point where the change is 
about to take place. Two or three of these spots may 
appear at a moderate distance from one another, and run 
together. The hair becomes white, and may fall out. 

The atrophy affects the skin and subcutaneous tis- 
sues ; the bones rarely undergo atrophy, though their 
growth may be retarded if the patient has not reached 
adult years. The muscles of the face are not subject to 
any fatty degeneration. Hammond found the muscu- 
lar fibers diminished in size. Owing to the loss of fat 
tissue and change in the skin, the cheek is hollowed in ; 
the skin, lacking in elasticity, seems to be closely ad- 
herent to the bone. Sometimes the tongue, the hard 
and soft palate, are affected ; the eye seems to be sunken 
deeper into its socket, and the lids are partially closed. 

There is no muscular paralysis ; the electrical reac- 
tions are normal ; the circulation is rarely disturbed ; 



UNILATERAL FACIAL ATROPHY. 325 

there is no change of temperature on the two sides of 
the face ; tactile sensation is not diminished. 

The disease does not lead to a fatal result, and no au- 
topsies have been made. Several theories have been 
advanced to explain the singular phenomena. It has 
been thought to be a disease of the cervical portion of 
the sympathetic, or of the nuclei of the facial or other 
cranial nerve ; of the spheno-palatine ganglion, or a 
primitive atrophy of the adipose tissue. 

~No treatment has been of permanent benefit. Elec- 
tricity has been thought to give a slight relief. Both 
the galvanic and faradic current have been applied 
locally to the face, but no permanent improvement fol- 
lowed. 



UNCLASSIFIED. 



CHAPTER XXVII. 

VEETIGO. 

Eussell, J., Illustrations of Stomachic Vertigo and Allied Af- 
fections. Med. Times and Gaz., July 3, 1880.— Jackson, J. H., 
Lecture on Auditory Vertigo. Lancet, Oct. 2, 1880, p. 525. — 
Fere, Ch., et Demars, A., Note sur la maladie de Meniere et en 
particulier sur son traitement par la methode de M. Charcot. 
Revue de med., No. 10, 1881. — Leven, Du vertige. Gaz. des hop., 
May 23, 1882, p. 468.— Woakes, E., Remarks on Vertigo. Brit. 
Med. Jour., April 28, 1883, p. 801. 

Frank defines vertigo as "an illusional turning, 
painful and sudden, which seems to affect the person 
himself and external objects, whether they are in re- 
pose or moving in their ordinary manner." 

Vertigo is really a symptom, not a disease. It may 
be reflex or sympathetic, or the cause may escape our 
observation, and then it is spoken of as idiopathic. 

Axenfeld has said that vertigo is caused by a change 
in the intra-cranial circulation, either a lack of suffi- 
cient arterial blood, or hyperemia, causing the symp- 
tom. In both these conditions the molecular inter- 
change in nerve-cells is incomplete ; their nutrition suf- 
fers ; their functions are exalted, exhausted, or per- 
verted. 

Causes. — Vertigo is sometimes caused by dyspep- 
sia. It is one of the symxotoms of exhaustion, of cere- 
bral anaemia, of intestinal or uterine disturbance. Va- 
rious poisons may produce vertigo, as tobacco, alcohol, 
opium, oxide of carbon, lead, prussic acid, or urremic 
poisoning. It is very common in certain cerebral dis- 
eases,, especially those affecting the cerebellum. Heart 



330 UNCLASSIFIED. 

disease is sometimes accompanied by vertigo. It may- 
be premonitory of various acute diseases, as the exan- 
themata. The petit mat of epilepsy is often simply 
vertigo attended with impaired consciousness. 

A disturbance of accommodation in the eyes, espe- 
cially if the eyes differ one from the other, may give 
rise to this disagreeable symptom. A slight weakness 
of some of the motor muscles of the eye, producing 
slight strabismus, may have the same effect. Of these, 
the causes are comparatively simple, and require little 
more than a mention. There is, however, a series of 
symptoms, due to disturbances of the ear, which de- 
serve more extended mention. 

Disease of the semicircular canals, or even a slight 
increase of pressure upon the fluid contained in these 
canals, is attended with vertigo. Even an accumula- 
tion of wax in the ear, or the closure of the Eustachian 
tube, may be sufficient to give rise to the symptoms. 

Vertigo, when caused by affection of the ear, was 
carefully described by Meniere, and hence has been 
called, from him, Meniere's disease. 

Besides vertigo, there is usually tinnitus, also deaf- 
ness, which in severe cases is complete. 

The attack is often sudden, the patient being obliged 
to stop, immediately seize hold of some object to sup- 
port himself, or perhaps he falls, as if suffering from an 
attack of epilepsy. There is, however, no loss of con- 
sciousness. His face is pale, his skin is cold, he is 
bathed in perspiration. There is nausea, vomiting, and 
headache. Many times the attack is less severe — the 
patient simply staggers instead of falling, and suffers 
severely from the accompanying symptoms. As a rule, 
the attack is not of long duration. The patient regains 
his steadiness and his usual health ; but, so long as the 
affection of the ear continues, there is danger of a re- 
newal of the vertigo. 

The treatment of auditory vertigo is, of course, first 
to remove any affection of the ear, any cause of press- 



VERTIGO. 331 

nre upon the semicircular canals. Charcot found great 
benefit from the use of seven to fifteen grains of qui- 
nine daily for nearly three months. If necessary, the 
quinine, after having been omitted, can be repeated 
when the symptoms recur. 

Sometimes electricity may be of benefit, though very 
rarely. 

It is important to make a correct diagnosis as to the 
cause of vertigo. Auditory vertigo is very likely to be 
mistaken for epilepsy, or for vertigo associated with 
dyspepsia. Unless a correct diagnosis of the cause is 
made, the treatment is likely to be futile. 

The treatment of other forms of vertigo must be di- 
rected, according to the cause, to the primary disease. 



CHAPTER XXVIII. 

CHOREA. 

Stukges, O., Some Statistics of Fatal Chorea. Lancet, July 
17, 1880, p. 85.— Mitchell, S. Weir, Lectures on Diseases of the 
Nervous System. Lectures VII, VIII. Philadelphia, 1S81.— 
Strange, W., Notes of 100 Cases of Chorea. Brit. Med. Jour., 
July 16, 1881.— Sturges, O., The Heart Symptoms of Chorea. 
Brain, July, 1881, p. 164.— Chapin, H. D., Points of Interest in 
Chorea. Med. Record, Dec. 15, 1883, p. 648.— Santini, G., Sulla 
patogenesi della corea. Rivista Sperimentale, ix, 1883, p. 449.— 
Sturges, O., Chorea with Rheumatism. Lancet, Aug. 31, 1878, 
Nov. 29, 1879, Sept. 20, 1884.— Houghton, J. H. Brit Med. Jour., 
Dec. 9, 1882.— Rickards, E. Ibid., Nov. 11, 1882, p. 932.— Fra- 
ser, T. R Ibid., Dec. 9, 1882, p. 1132. 

Chorea (Saint Titus's dance) may be denned as a 
neurosis affecting the voluntary muscles, generally pre- 
ceded and attended with slight mental disturbances, 
the motor phenomena consisting in irregularity of vol- 
untary motions, or, when severe, the spontaneous de- 
velopment of irregular motions apart from the inter- 
vention of the will. 

JEtiology. — Certain constitutional conditions un- 
doubtedly predispose to chorea. Heredity seems in 
some cases to be one of the predisposing causes ; the 
instability of the nervous system at certain periods of 
life, as during second dentition, and at puberty, are 
also to be taken into account, many more cases occur- 
ring from six to eleven years of age than at any other 
equal period. The disease is extremely rare after twen- 
ty-five years of age. The debility following scarlatina, 
diphtheria, typhoid fever, etc., frequently seems to 
predispose to the disease. Rheumatism appears to be- 



CHOREA. 333 

long rather to the exciting causes, considering the fre- 
quency with which it is followed by chorea. The re- 
lation which the two diseases bear one to the other is 
still an undecided question ; they occur together too 
frequently to justify us in considering the relation 
purely accidental. Chorea may appear before the child 
recovers from the rheumatism. 

The restraint and discipline of school life, especially 
public-school life, with its ambitions, oftentimes has 
an injurious influence. 

Among the more immediate causes of chorea may 
be mentioned sorrow, care, anxiety, fright, and irrita- 
tion. Occasionally chorea occurs during pregnancy, 
especially among primiparse, and most frequently dur- 
ing the twenty-first and twenty-third years of age. 

Symptoms. — The earliest symptom is a change of 
disposition. The child becomes restless, irritable, is 
thought to be getting nervous, or to have the fidgets. 
It loses its temper more easily, gives impertinent and 
saucy replies to its parents ; in fact, the whole nature 
of the child seems to have undergone a decided change 
for the worse. Much too frequently the parents and 
teachers consider the child disobedient and naughty, 
whereas it is entirely irresponsible for its conduct, and, 
instead of taking the proper measures to stop the dis- 
ease at its very beginning by curing a physical malady, 
they make it worse by employing reproof, punishment, 
and harshness to correct a moral delinquency that does 
not exist. This change of disposition may continue 
throughout the disease, and even extend beyond the 
time when motor disturbances have ceased. During 
the severest attacks there may be lack of mental pow- 
er, and inability or disinclination to apply the mind 
vigorously ; the expression of the patient may be al- 
most idiotic. 

After the above mental symptoms have existed a 
variable length of time, motor disturbance makes its 
apx^earance, as a rule beginning on one side and ex- 



334 UNCLASSIFIED. 

tending to the opposite side. Some authors say that 
the left side is the more frequently affected. Occa- 
sionally the motor disturbance is confined to one side 
during the entire disease. At first the irregular motion 
is slight, scarcely perceptible to an ordinary observer ; 
this irregular action of the muscles becomes more 
marked and constant. The face and upper extremities 
are in constant motion ; the patient is continuously 
making grimaces^ which at first may be thought volun- 
tary, and the child may be unjustly punished for 
" making faces." The fingers are flexed and extended, 
one or several at a time ; the child picks at its clothing, 
pulling and perhaps tearing it. When the lower ex- 
tremities are affected, the toes and legs are in constant 
motion, like the hands. Voluntary motion is inter- 
fered with ; the child is unable to write or sew ; often 
can not feed itself. Walking may also be difficult, or 
impossible. In extreme cases, not only are the limbs 
and face affected, but the body may also be turned and 
twisted and bent in various directions by the involun- 
tary action of the muscles of the trunk. The patient 
is unable to be up, is tossed about in bed ; the constant 
and violent motion causes excoriation of the skin ; he 
has a wan and haggard, perhaps a half-idiotic look, 
and is a pitiable sight. The respiration in severe cases 
is sometimes affected, acquiring a jerky character; 
speech may partake of the same jerky character, and 
it may even be almost impossible for the patient to 
speak. 

Except in very severe cases, sleep is not disturbed, 
and almost invariably the involuntary motions cease 
during sleep. In cases of moderate severity the pa- 
tients do not complain of being tired, and there is no 
appearance of exhaustion. Of course, this is not true 
of the severest cases. 

Sensation is but little if at all affected ; once in a 
while there may be pain, and sometimes tenderness, on 
pressure over the nerves. 






CHOREA. 335 

M. Rosenthal found that the reaction of the muscles 
to both the faradic and galvanic current was frequently 
increased. 

It is very common to find a cardiac murmur in cases 
of chorea, even where there has been no rheumatism 
preceding. It is not very rare to find an irregular in- 
termission of the pulse. As the patient recovers, the 
cardiac symptoms disappear, unless caused by organic 
lesion. 

A so-called post-hemiplegic chorea is one of the 
sequelae of cerebral disease. The motions may very 
closely resemble those of chorea. This has been de- 
scribed in connection with cerebral diseases. 

When the disease is caused by fright, and occasion- 
ally under other circumstances, the motor symptoms 
show great intensity at the commencement, the most 
violent irregular action appearing in the course of a few 
hours. These cases, however, are exceptional. 

Duration. — The duration of chorea differs greatly 
in different cases. Some patients recover in three or 
four weeks ; in others the disease is extended over 
several years ; the average duration is said to be two or 
three months. It is not uncommon for a child to suffer 
from two or even three attacks. Between these attacks 
the child is considered well, and is thought to have 
been cured ; but many times a careful observation will 
show that the irritability of the temper and changed 
disposition persist ; also, if the child' s hand is quietly 
held, a very slight spasmodic action of the fingers can 
be felt — too slight, perhaps, to be seen. 

Many cases, therefore, spoken of as recurrence of 
chorea, are in reality simply cases of remission of the 
severer symptoms. Dr. Mitchell mentions the greater 
frequency of chorea in the spring, and a tendency to 
recur the succeeding spring. 

Diagnosis. — The milder cases of chorea can hardly 
be mistaken, especially if their history is learned ; the 
description of the disease already given is sufficient for 



336 UNCLASSIFIED. 

diagnosis. There is a form of choreic disturbance which 
occurs after apoplexy, affecting the paralyzed side, 
which might be mistaken for genuine chorea. Charcot 
has well described this, and named it post-hemiplegic 
chorea. A history of the case showing the previous 
attack of paralysis, the fact that the affected limb still 
suffers from impaired power, and the difference between 
the involuntary motions in these cases and the irregu- 
lar action seen in genuine chorea, together with fre- 
quent presence of contraction, would assist in forming 
a diagnosis between the two conditions. 

In a few cases of cerebro-spinal sclerosis the irregu- 
lar involuntary motions become so general, and reach 
such a grade of severity toward the close of the dis- 
ease, that it is possible to mistake the affection and 
consider that the patient is suffering from chorea. In 
these cases the history of the disease and the general 
character of the motions, the fact that sensation is often 
affected in sclerosis, that contraction of the fingers and 
hand are more frequent, will aid in forming a correct 
diagnosis. These cases are, however, often very diffi- 
cult to distinguish from chorea. 

Pathological Anatomy. — The nature and seat of 
the lesion causing chorea are still undecided questions. 
Mild cases recover, leaving no disability ; only severer 
cases result in death : and therefore it is not without 
reason that many authors object to ascribing the milder 
cases to the same lesion as is found in the severer cases. 
In many autopsies the smaller blood-vessels of the brain 
have been found plugged. In some cases minute vege- 
tations have been found on the valves of the heart, ac- 
counting for the embolisms in the brain ; but these 
changes are not constant. The optic thalamus and cor- 
pus striatum are the parts chiefly or exclusively affected. 

It is specially interesting to recall the fact that in 
post-hemiplegic chorea, and in so-called athetosis, the 
lesions preceding these irregular motions are situated 
in the same portions of the brain in which these dis- 



CHOREA. 337 

eased arteries are found in chorea. Whether this por- 
tion of the brain is affected in sclerosis with exagger- 
ated tremor has not, to my knowledge, been a subject 
of investigation. It is also an interesting fact that bun- 
dles of nerve-fibers, passing through this region from 
the cortex, may be irritated so as to produce move- 
ments in the limbs similar to those produced by irrita- 
tion of the motor centers in the cortex. 

There is, therefore, a presumption in favor of a simi- 
lar causation of the irregular movements in all these 
affections. Whether the mild cases of chorea, ending 
in complete recovery, can ever be referred to an organic 
lesion of the brain, is extremely doubtful. A simple 
functional disturbance is sufficient to account for all the 
symptoms. Considering the mental phenomena, and 
the frequent hemiplegic character of the disease, af- 
fecting the face as well as the limbs, it must be looked 
upon as primarily of cerebral origin. 

Prognosis. — There is very little more to be said in 
regard to prognosis ; the milder cases always recover 
after a variable length of time, perhaps after two or 
three relapses. The older the child at the beginning of 
the disease, the more severe will it probably be, and 
the longer its duration. Death seldom occurs. In 
every case where I have seen such a result it has seemed 
to me that there was organic cerebral disease which 
caused the choreic symptoms and the fatal termination. 

Treatment. — The most active and meddlesome 
treatment has been advocated by some, and entire ab- 
stinence from medicine by others. In reality, mild 
cases probably do well without drugs. 

Hygienic and moral treatment is necessary in every 
case. The child should be noticed as little as possible ; 
its attention not called to its infirmity, unless it can be 
praised for improvement. Nothing more should be de- 
manded of the child than can be possibly helped ; the 
desires and wants of the child should be anticipated, 
and gratified as far as may be without over-indulgence. 
22 



338 UNCLASSIFIED. 

Of course, the child should be taken out of school, and, 
if necessary, removed from the society of playmates 
and the care of servants, who may irritate and annoy 
it by reference to its irregular movements. Common 
sense and knowledge of child nature will serve better 
than any written directions to guide this part of the 
treatment. Except in the severer cases, confinement 
to the bed and house is unnecessary. 

Arsenic has proved a most successful medicine. This 
should be given at first in moderate doses, then the 
dose rapidly increased to the limit of toleration. Thus, 
beginning with three or four drops of Fowler 1 s solution 
three times a day, the dose may be increased, by one 
drop every second or third day, until the child takes 
twelve or fifteen drops, or even more, at a dose. This 
remedy is to be thus continued, increasing the dose 
until either nausea follows or oedema below the eyes 
shows the approach of toxical effects. If nausea re- 
quires the drug to be discontinued, it should be re- 
sumed in the same dose as when omitted so soon as the 
nausea ceases. Unless given in large doses, no benefit 
can be expected. Many times it is of benefit to use 
iron also, and other tonics. Sulphate of zinc, in doses 
of three to five grains three times a day, has also been 
highly recommended. I have generally, however, 
found the arsenic sufficient. 

In severe cases, where the spasmodic action inter- 
feres with sleep, it may be necessary to give remedies 
to procure the needed rest. Of these, chloral is much 
the best. Perhaps paraldehyde would be as service- 
able. It is not desirable to give opium, or any of its 
preparations, if it can be avoided. Hyoscyamus, coni- 
um, and belladonna may be used as occasion requires. 
Calabar-bean has been used by Bouchut ; he employed 
•003 to "005 grm. three or four times a day subcutane- 
ously, with benefit to the patient. In many cases re- 
lief follows the application of ether spray to the back ; 
or ice along the spine may be used instead of the ether. 



CHAPTER XXIX. 

PARALYSIS AGITANS. 

Luys J., Contribution a l'etude anatomo-pathologique de la 
paralysie agitante. L'encephale, 1882. — Berger, Ueber Paralysis 
Agitans. Schmidt's Jahrb., 195, 1882, p. 246.— Buzzard, A Clini- 
cal Lecture on Shaking Palsy. Brain, Jan., 1882, p. 473. — Erlen- 
meyer, A., Beitrag zur symptomatischen Behandlung der Pa- 
ralysis Agitans. Cbl. f. Nervenheilkunde, Psych., etc., May 1, 
1883, p. 193. 

PARALYSIS AGITANS.— SHAKING PALSY.— PARKINSON'S DISEASE. 

Paralysis agitans is most common in old age, the 
name very well expressing its character — a tremor, more 
or less severe, attended with a weakness of the muscles, 
and a certain degree of stiffness. Violent emotions 
have sometimes been thought to be the cause ; but it is 
very doubtful whether such is the case. Otherwise we 
know nothing as to its aetiology. 

Symptoms. — The tremor is peculiar and character- 
istic, showing itself when the limbs are at rest, dimin- 
ishing or ceasing during voluntary motion, in this re- 
spect contrasting strongly with the tremor of sclerosis. 
The temperature is not increased, although there is 
such constant muscular action. Occasionally the trem- 
bling entirely ceases just before death. 

In the early stages of the disease the tremor is very 
slight, and is usually confined to the hands and fin- 
gers, often to the thumb and index-finger, which are 
rapidly adducted and abducted. At first this is a 
slight annoyance to the patient, and does not interfere 
seriously with his comfort or his ordinary pursuits. 
As the disease advances, however, the tremor affects 



310 UNCLASSIFIED. 

other muscles, becomes more marked, and greatly an- 
noys the patient. It does not cease entirely during 
voluntary motion of the parts, and so may interfere 
more or less seriously with the use of the hands. 

Opinions differ somewhat as to whether the head is 
affected ; it certainly is in some cases. 

After a while, to the tremor is added a weakness of 
the muscles — partial paralysis. There is also stiffness 
of the joints, the hands take a peculiar position, the 
thumb and index-finger being approximated, as if hold- 
ing a pen, and occasionally there is a slight claw-shape 
position of the fingers. 

The electrical reaction of the muscles is normal. 

In walking, the patient's head and body are bent 
forward, so that it seems almost as if he would fall 
upon his face. Instead of walking naturally, the pa- 
tient trots forward with short steps, as if the position 
of the body produced a sensation of falling, and he 
found it necessary to run in order not to pitch on his 
face. Sometimes there is compulsory motion back- 
ward instead of forward. The tendon reflexes have 
been noticed to be exaggerated in both the upper and 
lower extremities. Sensation is variously modified in 
some cases, and, when the disease is advanced, the 
mental powers suffer. There is sleeplessness and loss 
of memory, sometimes melancholia. 

Pathological Anatomy. — No satisfactory explana- 
tion of this disease has been proposed. Many careful 
autopsies show no change at all of the nervous system, 
and the pathological changes, if any, remain to be dis- 
covered, though there is a tendency among authors to 
refer the disease to some disturbance of the medulla 
oblongata. 

Diagnosis. — The diagnosis must be made from scle- 
rosis of the nerve-centers, with which this disease was 
formerly confounded. The difference in the character 
of the tremor, the positions of the hands in an ad- 
vanced case, are sufficient to distinguish the two. The 



PARALYSIS AGITANS. 341 

progress of the disease is also different. The cerebral 
symptoms are similar in only a few cases. They occur 
earlier in sclerosis than in paralysis agitans. 

The tremor of metallic poisoning, or of acholismns, 
may be diagnosticated by the history of the patient 
and by the progress of the disease. 

It is scarcely possible that post-hemiplegic chorea 
should be mistaken for paralysis agitans if the phy- 
sician is sufficiently careful. 

Prognosis. — Recovery is not to be expected. In- 
termissions may occur, but the course of the disease is 
generally forward. 

Treatment. — Very little can be said in regard to 
treatment. Some few drugs are of value as long as 
they are used ; but when given up, the tremor returns. 
Erlenmeyer found that chloral produced sleep, but had 
no influence upon the tremor. An infusion of valerian 
with bromide of potassium had a marked effect upon 
the tremor so long as it was used. Atropia always 
diminished the tremor, but he found it necessary to 
omit the drug on account of a slight toxic effect. 

Curare, when given subcutaneously in a dose of 
- 033 of a gramme, caused the tremor to diminish. This 
improvement continued about three days. 

Eulenberg recommends very highly the subcutane- 
ous injection of arsenic. He uses Fowler's solution 
diluted with two parts of distilled water, giving six to 
ten minims for a dose. These injections were continued 
daily, without unpleasant symptoms. In one case, 
fifteen injections, in another four, produced a very 
marked diminution of the tremor, lasting two months. 

Hyoscyamia has been recommended, but Erlen- 
meyer found that it had no effect unless given in toxic 
doses. 

The galvanic current may give relief, applying it to 
the head and neck ; but when the treatment is discon- 
tinued, the tremor returns. Static electricity has also 
been used with temporary benefit. 



CHAPTER XXX. 

EPILEPSY. 

Echeverria, M. G., On Epilepsy. New York, 1870.— Ben- 
nett, A. H., Analysis of 100 Cases of E. Brit. Med. Jour., March 
22, 1879, p. 419.— Jackson, J. H., Lectures on the Diagnosis of E. 
Med. Times and Gaz., Jan. 11, 1879, p. 29.— MacDonald, C. F., 
Feigned E. Am. Jour, of Insanity, July, 1880 ; Boston Med. and 
Surg. Jour., Dec. 30, 1880.— West, J. F., On Trephining for 
Traumatic E. Trans. Med.-Chir. Soc, 1880, p. 23.— Seguin, E. 
C, Importance of the Early Recognition of E. Med. Record, 
Aug. 6, 1881. — Lunier, Des epileptiques ; des moyens de traite- 
ment, etc. Annates med psycholog., March, 1881, p. 217.— Gow- 
ers, W. R., Epilepsy. London, 1881.— Marie, P., Note sur l'etat 
de la pupille chez les epileptiques. Arch, de nevrol., iv, 1882, p. 
42.— Beevor, C. E., On Knee- Jerk, etc., in E. Brain, April, 1882, 
p. 56.— Alexander, W., The Treatment of E. by Ligature of the 
Vertebral Arteries. Brain, July, 1882, p. 170.— Russell, J., The 
Remedies in the Treatment of E. before the Introduction of the 
Bromides. Practitioner, Feb., 1883, p. 81.— Weiss, J., Ueber E. 
und deren Behandlung. Wiener Klinik, April, 1884. — Ralfe, 
C. H., Seventeen Cases of E. treated with Sodium Nitrite. Brit. 
Med. Jour., Dec. 2, 1882, p. 1095.— Walsam, W. J., On Trephin- 
ing the Skull in Traumatic Epilepsy. St. Barth. Hosp. Rep., 
1883, p. 127. 

Epilepsy is a name given to an affection whose chief 
characteristics are attacks, recurring with more or less 
regularity, in which the patient partially or entirely 
loses consciousness, and is generally more or less con- 
vulsed, there being no organic disease to which these 
convulsions can be referred as a cause. 

Symptoms. — In about half the patients there is a 
warning aura, indicating the near approach of a con- 
vulsion. This aura may consist in an involuntary mo- 



EPILEPSY. 343 

tion, or a sensation in any part of the body or limbs, 
most frequently in the stomach; occasionally it is a 
sound, a sight, an odor, or it may be a confused mental 
action ; it precedes the attack a few seconds or minutes 
only. 

The attack may begin by a peculiar shrill cry, upon 
which the patient suddenly drops unconscious ; or, 
without this, consciousness is lost, and the patient falls, 
perhaps injuring himself. If the aura has given suffi- 
cient warning, he may be able to sit or lie down before 
the attack. 

In a very large proportion of cases the countenance 
changes, the face becomes pale, the eyes have a pe- 
culiar vacant look; tonic spasms seize the limbs and 
body ; the patient stiffens. The attack may begin in 
one limb and extend to the whole body, or it may be 
unilateral or bilateral throughout. During the tonic 
stage the limbs, face, and head may be drawn into un- 
natural positions ; there is frequently conjugate devi- 
ation of the eyes, with rotation of the head to one side. 

After a few seconds or minutes clonic spasms gradu- 
ally take the place of the tonic rigidity ; the limbs are 
jerked about, the muscles of the face and mouth are 
affected, there is frothing at the mouth, the tongue 
may be bitten. The patient is not tossed about much, 
as occurs in hystero-epilepsy. 

The countenance changes from pale to livid through 
venous congestion. The pupils are dilated, and do not 
react to light. There is conjugate deviation of the 
eyes, with rotation of the head to the opposite side 
from what it was during the tonic stage. 

Cutaneous reflexes, even of the conjunctiva, are 
abolished during the attack. 

The urine may be voided involuntarily, especially 
during nocturnal fits ; the faeces are less commonly 
passed during the attack. The spasms gradually de- 
crease in frequency ; the intervals between the contrac- 
tions are longer and longer, until there is quiet. 



344 UNCLASSIFIED. 

Immediately after the clonic stage, before return of 
consciousness, the patellar tendon reflex is increased, 
and ankle clonus is present in rather more than half the 
cases ; the tendon reflex is occasionally abolished. Dur- 
ing this period the pupils may oscillate, the eyes roll in 
unison from side to side. 

After lying quiet for a few minutes, the patient 
gradually comes to himself, being confused for a while. 
Often a heavy sensation in the head, or headache, suc- 
ceeds the attack, continuing a few hours or days. Some- 
times unilateral paralysis, or weakness, is noticed af- 
terward, and may persist several days. Unilateral 
anaesthesia after the spasm is probably found only in 
hystero-epilepsy. 

Many patients fall asleep immediately after the at- 
tack, sometimes before recovery of consciousness. This 
is scarcely natural sleep ; it rather resembles stupor. If 
the fit occurs during sleep, the patient may not awake, 
and in the morning be entirely unaware of what has 
occurred. Others will recover full possession of their 
faculties as suddenly as they lost them, without the 
least discomfort in the head or elsewhere. Sometimes 
the pulse is abnormally slow for several days, or even 
weeks, after the attack. 

In the full, complete attack of epilepsy, the loss of 
consciousness is absolute and entire. 

Attacks may be much less severe than those just 
described, consisting simply of a momentary loss of 
consciousness, without spasm of any kind ; or they 
may be reduced to the aura, consciousness not being 
interrupted, though mental activity and ability are un- 
doubtedly somewhat impaired. These attacks without 
convulsions are called petit mal ; those with convul- 
sions, grand mal. Every grade of severity is found, 
from the slightest ephemeral sensation to the severest 
convulsive attack. 

Many authors consider loss of consciousness neces- 
sary to constitute epilepsy. Nothnagel is right, how- 



EPILEPSY. 345 

ever, in saying that complete abolition of conscious- 
ness is not necessary to characterize the disease as epi- 
lepsy, " but that simple dizziness is sufficient ; in fact, 
any alteration whatever of the mental activity occur- 
ring paroxysmally, such as hallucinations and the 
like." 

Various unusual and exceptional manifestations of 
epilepsy deserve mention. Occasionally during the at- 
tack patients will perform acts which it would seem 
must be voluntary and conscious. In these the patient 
may simply perform some inoffensive act, as walking 
rapidly to a distance, or, as in one of my patients, a 
workman began to gather together pieces of wood, as 
if to carry home ; or the acts may involve more serious 
consequences, as pocketing various articles not belong- 
ing to himself, or making an attack upon by-standers, 
and, if the impulse is strong, the patient may be thrown 
into a frenzy, and may commit homicide. After these 
acts there is no recollection of what has been done dur- 
ing the attack ; there may be the same oppression in 
the head, and even the same tendency to sleep as after 
other attacks. Occasionally the patient seems to see 
objects which do not really exist ; there are hallucina- 
tions of sight. 

These unusual forms of epileptic seizures may co- 
exist in the same individual with the more common, or 
may precede the outbreak of the latter by several 
months or years, or may follow after a course of reme- 
dial treatment. 

The attacks vary greatly in frequency ; they may 
be separated by an interval of months, or even years. 
The earlier attacks occur usually at much longer inter- 
vals than the subsequent, when the disease is left to 
run its course without treatment. The attacks may 
occur many times a day. H. Hayes Newington reports 
(" Journal of Mental Sciences," April, 1877, p. 89) a case 
in which there were six hundred and twenty-two true 
epileptic fits in twenty-four hours. This great number 



346 UNCLASSIFIED. 

was excessive and unusual. Often from three or four 
to ten or a dozen may occur in the course of the day. 
It is very common to have the attacks recur in groups, 
several within a few hours or days ; then there is an 
interval of variable length free from attacks, and again 
a series of several in rapid succession. 

Epileptic fits may take place either during the day 
or in the night ; a large proportion occur in the early 
morning hours, just before or just after waking. It is 
impossible to estimate exactly the proportion of cases 
occurring during the night, as patients are often entirely 
ignorant of having had an attack. If one wakes with 
tongue bitten, bedclothes stained with blood and in 
much disorder, if the bed is wet, and there is discom- 
fort in the head in the morning, it is more than likely 
that there has been an attack. Any one of the circum- 
stances should give rise to suspicion in the case of an 
adult. After the attacks, small subcutaneous haemor- 
rhages may be seen, especially about the eyes and the 
rest of the face. These disappear in a few days. 

The patient' s limbs, and even his life, are not safe so 
long as he has the attacks. The fact of being in a po- 
sition of iminent danger sometimes seems to prevent 
the occurrence of the fit ; thus workmen, whose duty 
it is to ascend ladders or be on stagings, will sometimes 
be entirely free from fits in these exposed situations. 
It is, however, never safe to trust to such exemption. 
Epileptics suffer many times from bruises, and even 
from fractures or dislocations, as the effects of their at- 
tacks. They may also fall into the fire and receive 
severe burns. 

Death does not often occur during the fit. Some- 
times, however, cerebral haemorrhage is the direct re- 
sult of an attack. Occasionally the attacks recur with 
great rapidity, with scarcely a perceptible intermission ; 
the patient is in a state of epilepsy, status epilepticus, 
as it has been called, in which the fatal termination 
may occur. 



EPILEPSY. 347 

Between the attacks the patient may enjoy the most 
perfect health, and if the attacks are nocturnal, or occur 
in the early morning, he may be able to attend to all 
the duties of life — may even manage a large business 
without any one suspecting his infirmity. On the other 
hand, it is possible that the affection may lead to an 
impairment of mental powers, the memory at first be- 
ing weakened, finally imbecility or dementia closing 
the scene. This is more common when the disease be- 
gins in early life. A few rarely occurring very severe 
attacks have generally little influence upon the mental 
powers ; frequently recurring petit mal, giving friends 
much less concern, may more seriously undermine the 
intellect. 

The paralysis, which occasionally appears after the 
attack as an ephemeral symptom, may become perma- 
nent, continuing from one attack to the next. In such 
cases it is probable there is some organic cerebral le- 
sion. 

^Etiology. — Among those causes which give rise to 
a state of the nervous system predisposing to epilepsy 
may be mentioned heredity ; not that the ancestors 
have necessarily had fully developed epilepsy ; they 
may have shown only oddities of character, or mental 
extravagances, or they may have suffered from neural- 
gia or other neuroses. Parents addicted to the exces- 
sive use of alcoholic drinks may transmit to offspring a 
tendency to epilepsy. 

The frequency with which hereditary influence can 
be shown to exist in this affection — eighty times in three 
hundred and six, according to Echeverria — should lead 
to caution in regard to the marriage of epileptics. 

The excessive use of alcoholic drinks may develop 
a tendency to epilepsy in the subject ; such indulgence 
may also be the direct cause of the attacks. Some epi- 
leptics have the attacks only after a course of rather 
hard drinldng. 

The period of puberty is that in which the disease 



348 UNCLASSIFIED. 

is most likely to be developed ; much the larger num- 
ber of cases begin between ten and twenty -five years of 
age, or even between ten and twenty. 

Severe and prolonged convulsions in infancy are 
very frequently followed by epilepsy later in life. Ap- 
parently the cause of the earlier convulsions leads to 
changes in the brain, which favors their subsequent re- 
turn. 

Various depressing agents may be classed as pre- 
disposing causes, as worry, anxiety, grief, or excessive 
mental work ; but it is quite likely that many times 
there has been in these cases a predisposition to the 
disease in addition to the above depressing agents. 

Syphilis, especially if the bones of the skull are dis- 
eased, may be a cause of epilepsy. 

Disease of the bones, induced by injuries or by 
other causes than syphilis, may also give rise to at- 
tacks. 

The causes which may be more properly called ex- 
citing causes are blows or falls upon the head, whether 
giving rise to fracture of the skull or not, injuries to 
peripheral nerves, sunstroke, fright, anger or other vio- 
lent emotion, and lead-poisoning. 

Phimosis may be the cause of such an irritation as 
to give rise to epilepsy ; it would seem to be a pre- 
disposing cause, as giving rise to such a state of the 
system as to favor the occurrence of epilepsy, and it 
also may alone excite the attacks. The same reflex in- 
fluence may depend upon other sources of irritation, as 
that caused by teeth cutting through the gums. 

Occasionally serious disorders of digestion or im- 
prudence in diet seems to give rise to the attacks. 

At the best, however, it is often impossible to dis- 
cover the causes which lead to the development of the 
tendency, or give rise to the fits. 

Brown- Sequard found that after certain lesions of 
the nervous system, especially in Guinea-pigs, a por- 
tion of the face suffered a change in its nutrition such 



EPILEPSY. 349 

that irritation of the cheek would excite an epileptic 
attack ; such Guinea-pigs might transmit the tendency 
to epilepsy to their offspring. Several times a similar 
epileptogenous zone has been found in epileptic pa- 
tients. Otto reports a case of a patient the snapping 
of whose hat-elastic caused an attack. 

Diagnosis.— The diagnosis of epilepsy from hysteria 
and hystero-epilepsy will be more clear after their de- 
scription in the next chapter. 

The lighter attacks, the petit mal, may be recog- 
nized from common fainting or vertigo, by the regu- 
larity or frequency of their recurrence, by the brevity 
of the attack in epilepsy, by the occasional presence of 
an aura, by the occurrence of the grand mal at long in- 
tervals. 

The possibility of vertigo due to Meniere's disease, 
or the lithemic vertigo, should be kept in mind. 

Criminals and others try to simulate epilepsy to es- 
cape punishment or gain profit. A well-trained impos- 
tor is not easily discovered. The pallor of the face, 
the dilated pupils, reacting suddenly to light, can not 
be counterfeited, and it is scarcely probable that the 
cornea would be insensible to touch. A careful watch- 
ing of all the symptoms would lead to detection of 
impostors, unless they were remarkably well trained. 
(See MacDonald's case.) 

Prognosis. — Most patients with epilepsy are capa- 
ble of improvement ; few can be expected to recover. 
The earlier in life the attacks begin, and the longer 
they have persisted, the less favorable is the prospect. 

If a definite cause can be discovered, as teething, 
sunstroke, lead-poisoning, syphilis, etc., the chances 
are in favor of recovery in proportion to the readiness 
with which these causes can be removed, if the disease 
has not been of too long duration. 

Mental failure is rare when the attacks begin after 
puberty, except in syphilitic cases ; when they com- 
mence early in life, the mind is much more likely to fail. 



350 UNCLASSIFIED. 

Teeatment. — If any source of peripheral irritation 
can be discovered which may act as cause of the fits, 
that should be removed, as cicatrices, phimosis, or irri- 
tation of gums by teeth. If fracture of skull or de- 
pression, fragments should be removed or raised. 

The remedy which has been found most useful is 
the bromides. It is rather a matter of taste as to which 
bromide should be employed ; the potassic, sodic, calcic, 
and lithic salt act very nearly alike. Sometimes an 
idiosyncrasy on the part of the patient will be a guide 
in the choice. 

G-owers's method of giving the bromides is somewhat 
different from the ordinary way, and is of value. He 
gives very large doses at the beginning of treatment — 
two or three drachms every second or third morning, 
increases the dose to four drachms every fourth morn- 
ing, and six drachms or an ounce every fifth morning. 
These large doses should be given after breakfast, in a 
tumblerful of water. When drowsiness and mental 
dullness follow during the rest of the day, he does not 
increase the dose. More than an ounce is rarely borne. 
The maximum dose should be reached in two or three 
weeks and repeated three or four times, and the doses 
then gradually reduced ; the whole course lasts six or 
seven weeks. Unless the attacks cease entirely when a 
dose of four drachms is reached, he gives up the effort 
to cure the patient. After omitting the bromide a 
week or two, he gives it again regularly in smaller 
doses, twenty grains or more three times a day. 

The usual method of giving bromide is to give a 
dose three times a day ; usually the dose is too small. 
It is necessary to begin with at least fifteen or twenty 
grains three times a day, and the dose should be in- 
creased rapidly till some evidence of its action is ob- 
tained. Patients may take sixty to ninety grains of 
bromide a day for six or ten years without injury. 

When large doses are given, acne appears on the 
face, back, etc. ; three to five drops of Fowler's solu- 



EPILEPSY. 351 

tion with each dose of the bromide will tend to prevent 
this. In very large doses patients sometimes find their 
legs getting weak, or lose their memory. If the dose 
is diminished or omitted for a few days, these symp- 
toms disappear. In excessive doses, delirium and 
symptoms resembling meningitis may be produced. 
Of course, this ought to be avoided. 

Iron, cod-liver oil, and quinine may be given to ad- 
vantage with the bromides. 

Occasionally the bromides seem to lose their bene- 
ficial effect, or the patient becomes disgusted with the 
drug. Ralfe recommends then the use of sodium ni- 
trite, free from the nitrate. 

Atropia is frequently used, either with the bromide 
or alone, sometimes with benefit. With it, or the ex- 
tract of belladonna, may be used valerianate or oxide 
of zinc, and extract of hyoscyamus. 

Digitalis is sometimes combined with the bromides. 

Kunze * used curare subcutaneously, in 0*03 gramme 
doses, every fifth day for three weeks, then waited for 
the next attack, and repeated. The first sign of toxic 
action is a blurred vision. 

Wildermuthf gave, with bromide, osmic acid 0*002 
gramme in watery solution or pill, or 0*004 gramme 
potassic osmate, with benefit in an old, obstinate case 
when bromides alone failed. 

During an attack the patient's clothes should be 
loosened ; he should be prevented from injuring himself 
if the clonic convulsions are violent. A towel rolled 
firmly into a cone, or a piece of cork or rubber, should 
be put between the teeth, to prevent biting the tongue. 

When an aura gives opportunity, the inhalation of 
nitrite of amyl may cut the attack short. Patients 
sometimes learn that by firmly seizing the limb in 
which the aura is felt, or by tightly bandaging it, they 
can arrest the lit. 

* " Wien. med. Presse," Oct. 20, 1878. 
t "Berl. kl. Wochenschr.," June 9, 1884. 



352 UNCLASSIFIED. 

In the status epilepticus, inhalation of nitrite of 
amyl sometimes is beneficial. Gowers finds the most 
good from repeated doses of chloral, morphia subcu- 
taneously, and the application of ice to the spine. 

The diet should be simple and unstimulating. It is 
well to restrict the use of animal food to a small amount 
once a day, or forbid it entirely. This diet is most 
valuable with young patients. 



CHAPTER XXXI. 

HYSTERIA AND HYSTEEO-EPILEPSY. 

Richter, Ueber psychische Therapie motorisclier Storungen 
der Hysterie. Berl. M. Wochenschr., June 14, 1880, p. 341. — 
Mitchell, J. Weir, Lectures on Diseases of the Nervous System, 
especially in Women. Philadelphia, 1881. — Debove, L'hysterie 
chez l'homme. Gaz. des hop., Nov. 20, 1882, p. 1070. — Huchard, 
H., Caractere, moeurs, etat mental des hysteriques. Arch, de 
nevrol., iii, 1882, p. 187. — Axenfeld, Traite des nevroses. Paris, 
1883.— Dujardin-Beaumetz, On the Treatment of Hysteria. Med. 
News, Aug. 4, 1883, p. 113.— G-rasset, The Eelations of Hysteria 
with the Scrofulous and the Tuberculous Diathesis. Brain, Jan., 
July, 1884. 

Richer, P., Etudes clinique sur l'hystero-epilepsie, ou grande 
hysterie. Paris, 1881. — Mills, 0. K., Hystero-Epilepsy. Am. 
Jour. Med. Set., Oct., 1881, p. 392.— Welponer, E., Exstirpation 
beider Ovarien wegen Hystero-Epilepsie, Heilung. Wien. med. 
Wochenschr'., No. 30, 1879.— Walton, G-. L., Hysteria, as affected 
by Removal of the Ovaries. Boston Med. and Surg. Jour., June 
5, 1884, p. 529.— Peckham, G-., Metallotherapy, Theoretically and 
Practically Considered. Archives of Med., Dec, 1883, p. 283. — 
See, also, on Metallotherapy, Charcot, Lancet, 1878, i. — West- 
phal, Berl. Tel. Woch., 1878, p. 441.— Wilks, Brit. Med. Jour., 
July 20, 1878. 

HYSTERIA. 

Hysteria is often described as a functional disease 
of the nervous system ; it would be more exact to 
speak of it as a diseased or abnormal state of the nerv- 
ous system, revealing itself by peculiarities of tempera- 
ment, of thought, action, and affection, with occasional 
outbreaks of motor or emotional disturbance. 

Formerly the convulsive phenomena were considered 
as essential ; but, while their importance is still recog- 

23 



354 UNCLASSIFIED. 

nized, more attention has been recently given to the 
state of the nervous system, which renders these phe- 
nomena possible. 

./Etiology. — Briquet says half the women have a 
predisposition to hysteria — that is, they are very im- 
pressionable. This predisposition is also seen in a few 
men, and a small number of males are attacked. 

The age at which the affection is most common lies 
between puberty and twenty years. After that age 
there is a gradual diminution in the proportion of pa- 
tients. Among young girls Briquet found about a 
quarter or a fifth as many cases as among those who 
had commenced to menstruate. There are many cases 
reported as occurring in boys. 

Heredity plays an important part in predisposing to 
hysteria. It will often be found that some form of 
nervous disturbance is prevalent among the relations of 
such patients. Huchard says that in hysterical women 
it will be found thirty times in one hundred cases that 
the parents have been hysterical, but in women not 
thus affected only four times in one hundred cases will 
this be found to be the case. Briquet found that a little 
more than half the hysterical mothers had transmitted 
the affection to their daughters. 

It can not be doubted that the training to which 
young girls are subjected influences the predisposition 
to hysteria ; their home training and school training, 
their food, exercise, clothing, the amount of sleep ob- 
tained, the amusements allowed, the self-restraint which 
they may be taught — these and many other conditions 
either increase their natural predisposition or dimin- 
ish it. 

And not only do children show the effect of their 
mode of life ; older women show it also, and a tendency 
to hysteria may be created, or, if existing, may be 
neutralized, by the surroundings of the patient and by 
those indulgences which she allows herself, or by those 
privations to which she may of necessity be exposed. 



HYSTERIA. 355 

Whatever lowers the healthy tone of the system, as a 
whole, may serve indirectly as a cause of hysteria : the 
depressing passions, care and worry, disease of any or- 
gans, but more especially of the uterus and its append- 
ages, may give rise to the state of the nervous system 
which favors the development of the affection. 

Accidents and bodily injuries must be counted 
among the predisposing causes of hysteria. Those ac- 
cidents which are accompanied with nervous shock and 
fright, as when a horse runs away with the carriage in 
which the patient is riding, or railroad accidents, are 
most likely to give rise to this state of the nervous sys- 
tem. 

Some of these causes which act as predisposing to 
hysteria may become the direct cause of an attack in 
patients who are otherwise predisposed thereto. Imi- 
tation may give rise directly to an attack. 

Symptoms. — In hysteria there is found a perversion 
of certain faculties and characteristics of the patients. 
There is a paralysis or weakness of the moral sense and 
of the will, an exaggeration of the emotions and the af- 
fective faculties, with irregular and perverted action of 
the cutaneous, visceral, and special senses. Nearly, if 
not quite, all the phenomena of hysteria can be ex- 
plained by supposing the above changes. 

The special manifestations of hysteria in different 
patients are almost as varied as are the diseases to 
which humanity is liable. Even in ordinary health 
these patients show a nervous mobility, a habit of ex- 
aggeration, a morbid desire for sympathy, an excessive 
sensitiveness and ardent imagination which is charac- 
teristic. 

The disturbance of the moral sense may show itself 
simply by persistent exaggeration of symptoms — an ex- 
aggeration which almost amounts to simulation ; or 
there may be deliberately planned simulation. The 
patient will pretend to have symptoms which do not 
exist ; she will produce haemorrhage from some portion 



356 UNCLASSIFIED. 

of the mouth, and pretend to have haemoptysis ; she 
will pretend to vomit urine instead of secreting it by 
the kidneys ; and perhaps, in order to keep up the illu- 
sion, she will drink her urine immediately after passing 
it. The patient may pretend that she is paralyzed, or 
is so weak that she is unable to rise ; yet, when she 
thinks herself alone, she may be seen to rise and cross 
the room. 

A more serious and important exhibition of this 
propensity for lying is occasionally met in hysterical 
women ; they will accuse a physician or dentist or 
priest of taking improper liberties with them, or of vio- 
lating them. The records of legal medicine contain 
many such instances. 

The foundation for some of the complaints of the 
hysteric may be a real discomfort ; this discomfort or 
pain is exaggerated by the patient. A slight pain in 
the eyes, when open to the light, is exaggerated into 
severe photophobia, and the patient must remain in a 
dark room ; yet when the oculist wishes to examine the 
eyes the light is born without complaint, and even the 
ophthalmoscope can be used without the patient's com- 
plaining. A slight discomfort in swallowing is exag- 
gerated into entire loss of power to take food, and, if a 
sound is passed, a very persistent spasmodic stricture 
may be found. So it may be in regard to other symp- 
toms ; but it will often be very difficult to judge wheth- 
er there is any foundation at all for the pretended ina- 
bility. 

The disturbance of the emotions and affections is 
sometimes very marked in hysterics. Huchard thinks 
it is not common to find excessive sexual excitement in 
hysterical patients ; that sexual desire may be entirely 
lost. Other passions may be exaggerated ; they easily 
acquire a repugnance for persons ; they long for atten 7 
tion and manifestations of love from others. This pe- 
culiarity may lead to the simulation of disease ; but in 
much the greater proportion of hysterical patients it is 



HYSTERIA. 357 

shown only by a claim upon the attendants or members 
of the family for care and attention. Self is elevated to 
the highest place in these patients, and self must be 
served first and always. A mother may exact from a 
daughter constant attendance, even at the price of ruin- 
ing that daughter's health ; a daughter may be jealous 
of brothers and sisters, and become worse whenever the 
mother tries to give care to other members of the 
family. 

Sometimes the patient has only one class of symp- 
toms ; probably, in such cases, there is real disease, 
pain, or discomfort, as a foundation for her complaints. 
At other times the complaints and symptoms vary from 
week to week, or in different attacks ; even during the 
physician's visit she may recite a long list of ill- con- 
nected symptoms, inconsistent with one another. 

" They love to carry everything to extremes, do not 
know how to live in simplicity ; they exaggerate all 
their feelings, indifference as well as enthusiasm, affec- 
tion as well as antipathy, love as well as hate, joy as 
well as despair, and they dramatize everything on the 
great stage of the world, where they are, and always 
remain, true comedians." 

The intellectual condition of hysterics is generally 
unnatural. They are not able to turn their minds to 
the more serious occupations in which they may have 
once engaged ; those who have been familiar with their 
mental power when in health will probably find that 
there has been a loss therein. Though this is true of 
the higher and more complicated processes of thought, 
yet in the ordinary round of daily life, and on a lower 
plane, their mental activity may be exaggerated, their 
conversation may be lively, animated, witty, and en- 
tertaining ; they may appear even brighter than is 
natural, perhaps relapsing soon into silence and indif- 
ference. 

The special senses, particularly hearing and smell, 
may be abnormally acute ; occasionally hallucinations 



358 UNCLASSIFIED. 

of sight, hearing, or odor may be noticed, though it is 
necessary to guard against error as to the two last 
senses, the patient noticing sounds and odors which 
are not perceived by the attendants. Perversion of 
taste may lead to a distaste for certain articles of diet, 
or a desire for abnormal articles. 

Ordinary sensation may be diminished or increased 
in acuteness ; such changes are more frequent in the 
form called hystero-epilepsy than in simple hysteria, 
yet even this will show at times abnormal conditions of 
sensation. 

Pain may be felt in different regions, and, as has 
been noticed, the acuteness of the pain may be much 
exaggerated by the patient. Headache is not uncom- 
mon, and backache is often met in these patients. The 
pain may be very severe just below the breast, espe- 
cially on the left side. There may be severe pain and 
tenderness in the joints, simulating arthritis. It would, 
however, require much too large £ space to enumerate 
all the changes of this nature which may be found in 
hysterics. 

Sometimes there is a great diminution of the urinary 
secretion ; and there may be even a temporary suppres- 
sion, which has been known to extend over some days. 
Charcot reports a case, observed during four months, 
in which there was a great diminution in the amount 
of urine, an average of three grammes during August ; 
on several occasions there was total suppression, once 
for eleven days. The patient vomited much, and the 
vomitus contained urea. 

Among other abnormal conditions may be mentioned 
excessive sweating, disturbance of the gastric secre- 
tions, enormous secretion of gas in the stomach and in- 
testines. 

Paralysis affecting various parts of the motor sys- 
tem is sometimes seen, affecting an entire limb, or only 
a few muscles. Muscles thus affected give a normal 
reaction to the electric current. It is said by some that 



EYSTEBIA. 359 

normal response to the motor irritation, with loss of 
sensitiveness to the current, is diagnostic of hysterical 
paralysis. If the anaesthesia is extreme, and the reac- 
tion perfect, this may be an aid to diagnosis, but it is 
not alone sufficient to found a diagnosis upon. Instead 
of total paralysis, there may be contraction, persisting 
for months or years. 

Aphonia may be hysterical in its origin ; the patient 
may lose her voice entirely, and be obliged to have re- 
course to signs to make herself understood, or there 
may be an ability to whisper. This hysterical aphonia 
is rather intractable, and is very likely to recur. 

The symptoms above noticed may appear in dis- 
tinct attacks, between which the constitutional pecul- 
iarities are still to be noticed, but in less marked de- 
gree. 

There are other attacks, attended with more or less 
violence, which are more generally known as hysterical 
attacks. These crises are attended with spasmodic ac- 
tion, or with excessive emotional disturbance ; often 
begin with a sensation as if a ball rose from the epi- 
gastrium to the throat {globus hystericus), or that may 
be the whole of the spasmodic attack. Then, when 
this sensation has reached the throat, there is a general 
spasm, attended with screaming, with crying and sob- 
bing, mingled with wild laughter. Sometimes this 
spasm commences suddenly, without the preceding 
aura. During the attack the patient seems to be un- 
conscious, yet afterward may have a recollection of 
most that occurred. The heart may beat rapidly and 
strongly ; the respiration is accelerated ; the patient, 
feeling a sense of suffocation, may clutch at her throat, 
and try to tear her clothing. Muscular movements in 
these attacks are generally co-ordinated to accomplish 
some purpose, and are semi- voluntary, or entirely un- 
der the control of the will, though that will may be 
perverted. These attacks last from a few minutes to a 
few hours. 



360 UNCLASSIFIED. 

After the attack the patient is usually exhausted, 
lies still, with eyes shut, is disinclined to speak, and 
may seem more than half ashamed. Commonly a large 
amount of pale urine, of low specific gravity, is voided 
soon after an attack. 

HYSTERO-EPILEPSY. 

Charcot first, and later his pupils and others, have 
given descriptions of attacks occurring in hysterical 
patients which seem to be combinations of epilepsy 
and hysteria. Gowers, indeed, considers these to be 
hysteria added to and occurring after epileptic at- 
tacks. 

In this manifestation of disordered nervous action 
there are more or less distinct attacks, with periods of 
remission, or rarely intermission of symptoms. 

The convulsive attacks never occur without warn- 
ing. The patient shows a change in her disposition, 
becoming irritable, moody, gay and lively, or sad and 
desponding. She may be quiet or restless ; she may com- 
plain of headache, or of pain elsewhere, especially in 
the ovarian region. There may appear also, before the 
fully developed attack, the hypersesthesia and the an- 
aesthesia of one side or the other, as is seen between 
the convulsive attacks. These prodromes, especially 
the psychical, may appear even several days before the 
attack. 

The attack is divided by Richer and others into four 
periods : 

1. The epileptoid. 

2. That in which contortions prevail. 

3. Period of emotional attitudes. 

4. Period of delirium. 

The epileptoid period is immediately preceded by 
slight convulsive movements, as winking the eyelids 
with extreme frequency, general tremor, and rapid 
respiratory movements ; during this prodromic stage 
consciousness is retained ; it seems sometimes as if un- 



HYSTERO-EPILEPSY. 361 

usual interest in the phenomena hastens the advent of 
the convulsions, during which consciousness is lost. 

The fully developed epileptoid attack very closely 
resembles an attack of true epilepsy ; first there is a 
rigidity of the body and limbs, with a slow motion of 
different parts, the body is slowly bent back, the neck 
is swollen, or the head slowly turns to one side. The 
face is pale, then congested ; the features are distorted ; 
the limbs are slowly and stiffly moved, usually turned 
on their axis, or flexed and extended ; the arms assume 
the position of extreme pronation ; the legs are strong- 
ly adducted ; the feet turned inward or outward. 

This is followed by a short stage of rigidity, with- 
out motion ; the patient remains immovable in the 
position in which she is found at its beginning ; usual- 
ly the body is extended, in dorsal decubitus, with the 
head bent back slightly, the arms extended, pronated ; 
or other postures may be assumed. The whole dura- 
tion of this stage may be a minute. 

Next follows a stage of clonic convulsions of limited 
excursion, sometimes general, sometimes unilateral ; 
these resemble the clonic convulsions of epilepsy. 
Muscular resolution is next seen, with stertorous res- 
piration, and frothing at the mouth. The clonic stage 
lasts about a minute ; that of muscular resolution a few 
minutes. 

The second of Richer' s periods may be divided into 
that of illogical attitudes and that of great movements. 
In the first of these the patient assumes the most 
varied, extraordinary postures with great force, ex- 
treme opisthotonus being the position most frequently 
assumed. 

The stage of great movements is characterized by 
rapid, alternating motions of flexion and extension of 
the body ; the limbs may also be moved about. At the 
beginning of this stage the patient may utter a pierc- 
ing cry, or she may strike herself, or tear her hair or 
clothing. 



362 UNCLASSIFIED. 

In the second period the loss of consciousness is not 
complete. The contortions are of longer duration than 
the epileptoid spasms, sometimes five or ten minutes ; 
there is no foaming at the mouth, no suspension of the 
respiration, no inspiratory spasm, and, consequently, 
no turgescence of the face. 

The third period is that of hallucinations. The pa- 
tient's words and gestures are in harmony with her hal- 
lucinations. General and special sensibility are abol- 
ished. 

This third period may imperceptibly merge into the 
fourth, or that of delirium, in which the patient seems 
to review the events of her past life. With this the 
attack may cease, the patient often passing a large 
amount of pale, clear urine. 

Curious and important phenomena in these patients 
are connected with the effects of pressure over certain 
areas of the body. This pressure may give rise to an 
attack ; these spots differ in different patients, and 
sometimes corresponding spots on both sides of the 
body must be pressed. These regions are just above 
the breasts, just below the breasts, under the axillae, just 
over the crests of the ilia, between the scapulae, and over 
the ovaries. Immediately after an attack, pressure over 
the hysterogenic zone may not induce another. 

Another phenomenon is that pressure over one ova- 
ry — that which between the attacks is hyperkinetic — 
will often cause the attack to cease immediately. The 
patient, though violently convulsed, falls on the bed 
entirely relaxed, and may soon recover consciousness ; 
sometimes, however, another attack succeeds before 
consciousness is fully restored. This pressure must be 
directed so as to affect the ovary, and it may be neces- 
sary to use great force to obtain the result. 

When the hysterogenic zone is not in the ovarian 
region, pressure over that zone may cause the attack to 
cease, or it may cease from pressure only when that is 
exerted over the ovary. 



HYSTERO-EPILEPSY. 363 

During tlio attack the eyes are ansesthetic, even dur- 
ing the period of delirium, and the cornea may be 
touched without exciting reflex movements of the lids ; 
sometimes tears will flow after such a test, and some- 
times the eye remains dry. 

The variations of the pupils have been studied late- 
ly by Fere. During the attack the pupils are, as a rule, 
only slightly influenced by the light. During the first 
part of the first period the pupils remain contracted ; 
immediately at the commencement of the second part 
of this period, when the clonic spasms set in, they are 
widely dilated, and remain so until the period of emo- 
tional attitudes ; during that, and the period of deliri- 
um, the pupils contract and dilate according to the 
nature of the hallucinations, whether the objects pre- 
sented to the mind seem to be near or remote. 

Of course, in imperfect attacks, all these phases of 
the pupils may not be seen. Yet Fere noticed in one 
instance, where the attack consisted only of the great 
movements, in which the pupils are dilated, that before 
the attack the pupils contracted with great energy, 
though there was no sign of other contraction. 

The condition of patients between the attacks is 
peculiar and interesting. As a rule, there is hemian- 
esthesia, affecting the side opposite the tender ovary, 
yet there are exceptions to this rule where the loss of 
sensibility is on the same side. The side which is not 
hemianesthetic is in a state of hyperesthesia. 

Not only is there loss of general sensation, of touch, 
and pain, but the special senses are affected on the 
same side with the general sensibility ; sight, hearing, 
smell, and taste may all be diminished on that side. 

Fere has carefully studied the condition of the eyes 
in these patients. He finds the field of vision limited, 
almost reduced to nothing, with complete loss of per- 
ception of color. In such patients there is complete 
anaesthesia of the conjunctiva and cornea; the reflex 
action of pupil and lids is also much interfered with. 



364 UNCLASSIFIED. 

In other patients there may be only a moderate limita- 
tion of the field of vision, and partial loss of perception 
of color. These two kinds of visual defect generally 
show a direct relation and harmony between them- 
selves. Where there is only partial loss of visual pow- 
er, the anaesthesia of the eyeball varies according to the 
amount of visual disturbance. 

Diagnosis. — Sometimes the general physiognomy 
of the patient reveals to the physician that he has to 
do with a hysterical case ; again, the singular combi- 
nation of symptoms presented is sufficient to give a 
clew to the nature of the affection. 

Where there are no convulsive attacks, when the 
patient imagines disease of some organ, the physical 
examination of that organ, and a comparison of the 
symptoms with those which ought to be present, will 
often be sufficient for a diagnosis. It may not be pos- 
sible to arrive at a conclusion immediately, but careful 
observation of all the symptoms will generally lead to 
a correct diagnosis within a few days. 

When the hysterical simulation takes the appear- 
ance of nervous diseases, it may not be easy to decide 
whether there is real disease. If the history of the pa- 
tient and of the attack can be obtained, the task will 
be less difficult. As it would be awkward, to say the 
least, to treat as hysterical a patient who has a real or- 
ganic lesion, great care in the first examination, and 
careful watching of changes, is essential. If the pa- 
tient, by inheritance, age, and temperament, seems to 
be predisposed to hysteria, if the disease can be re- 
ferred to some disturbing emotion, if its symptoms are 
singular and in striking contrast to those arising from 
any organic lesion, and if there is much variation from 
time to time in the symptoms, such as renders the exist- 
ence of organic disease almost impossible — if these con- 
ditions exist, it may be safe to diagnosticate hysteria. 

The diagnosis of the convulsive hysterical attacks 
from epilepsy is not always easy. The fully developed 



HYSTERIA. 365 

attack of hystero-epilepsy is not to be mistaken ; bnt 
the imperfect, partial attacks may not be at once rec- 
ognized. 

The aura is not the same ; the globus liystericus is 
rarely met in true epilepsy. The manner in which the 
patient tells about the aura will sometimes aid in form- 
ing an opinion as to the nature of the attacks. The 
hysteric almost never falls suddenly, as the epileptic ; 
there is a gradual sinking, and ability to save one's 
self from injury. Except in hystero-epilepsy, con- 
sciousness is not totally abolished in hysteria ; the pa- 
tients will remember somewhat of the events during 
the attack. The convulsions last longer in hysteria, 
and are more varied ; they are also of wider excursion ; 
the patients throw themselves about more. As the at- 
tack ends, its hysterical nature is sometimes clearly re- 
vealed by the sobbing and crying, or by the attack of 
laughing which follows. The state of the patient be- 
tween the attacks will be an important aid to diagnosis. 
The epileptic, after the heaviness and dullness, or pa- 
ralysis, which is sometimes seen after an attack, has 
passed, is as well as ever, and shows no sign of disturb- 
ance, unless the disease has begun to affect the mind. 
The hysteric has the psychical peculiarities between the 
attacks which have been previously described. If a 
large amount of pale urine, of low specific gravity, is 
passed immediately after an attack, the chances are de- 
cidedly in favor of hysteria. 

Peognosis. — Life is not in any special danger from 
hysteria. When once the predisposition has developed 
into the actual hysterical state, recovery is at best a 
distant possibility. The favorable termination will de- 
pend upon how thoroughly the patient's constitution 
has been undermined by early education and trials, and 
upon how much can be done to restore a natural vigor 
to the nervous system. 

When the predisposition is slight, or absent, treat- 
ment is much more likely to be successful. 



366 UNCLASSIFIED. 

Relapses are very likely to occur ; a patient may be 
well for many months, until some excitement or emo- 
tion awakens again the symptoms. 

In hystero-epilepsy the prospect of recovery from 
the earlier attacks is the more favorable. As the fre- 
quency of the attacks increases, the prognosis becomes 
more grave. 

Tkeatment. — Treatment should begin with children 
of neurotic parents about as soon as they are bom, to 
prevent, if possible, the development of the hysterical 
predisposition. Care in regard to the child's surround- 
ings, its food, exercise, sleep, study, and government, 
is to be continued throughout childhood and youth. 
Sometimes the mother is not suitable to look after the 
child, and the care must be given to others. In all 
such cases the family physician has it in his power to 
do much by advice and warning. Huchard formulates 
this line of treatment thus : "To favor the physical de- 
velopment at the expense of the moral and intellectual 
development." 

After the disease has once shown itself, it will be 
necessary to use all the hygienic means at one's com- 
mand to counteract the predisposition, and the pa- 
tient's life may need to be watched and regulated for 
months or years. Often this can be done better away 
from home. The patient is self-willed, and needs to be 
under control, which will not be exercised at home. 

As disease of one of the viscera may be a principal 
cause of hysteria, every organ should be examined, 
and, if really diseased, the disorder should be corrected 
if possible. The physician will, of course, bear in 
mind the fact that functional disturbances may be 
found in any part of the system. He will also do well 
to bear in mind that too much notice given by him to 
any organ may call the patient's attention to that part 
of the body, and so its condition be made worse. This 
tendency of the patient may be utilized by the physi- 
cian to turn the patient's attention away from the dis- 



HYSTERIA. 367 

eased organ while he really administers medicine for 
that. ' 

The management of the patient between the attacks 
is of great importance ; or, if there has been no fully 
developed attack, but only such an unstable nervous 
condition as to give rise to fear of an attack, the gen- 
eral management is important. This will include hy- 
gienic and dietetic agencies ; but care must also be 
given to develop the patient's power of will, of self- 
restraint, and her ability to meet and resist* the ordi- 
nary little disturbances which arise in daily life, as 
well as the more serious trials. The physician would 
not be wise to entirely ignore the patient's complaints ; 
he should not set aside the symptoms mentioned as en- 
tirely imaginary, but, while letting the patient feel that 
she has his sympathy, and that he understands her 
troubles, he should also show her that, by a resolute 
effort of will, she can do much to help herself. He can 
not do this on the first visit, nor perhaps until after he 
has allowed time enough to elapse to win her confi- 
dence. In other cases, comparative harshness and dis- 
regard of complaints from the first will have a better 
effect. It will sometimes be necessary to remove the pa- 
tient from home, and to seclude her in a measure, or en- 
tirely, giving her into the care of kind but firm nurses. 

The boundary between hysteria and insanity is by 
no means well defined, and the question may arise as to 
the propriety of asylum treatment. Each case must be 
judged upon its own merits. 

Of drugs which may be used, those which will act 
as tonic to the nervous system, and increase the vigor 
of the health generally, should be given, in order to 
remedy the natural predisposition of the patients. Be- 
sides the ordinary tonics, arsenic, zinc, and phosphorus, 
in their different pharmaceutical forms, may prove of 
benefit ; valerianate of zinc, in two- or three-grain doses, 
is specially valuable. Cod- liver oil, or, if that can not 
be taken, cream, is a useful addition to the diet. If the 



368 UNCLASSIFIED. 

heart is irregular or feeble, a short course of digitalis 
may be of value. 

Hysterical patients are very often addicted to the 
use of preparations of opium to relieve real or imagi- 
nary pain. Opiates should be used with extreme cau- 
tion. A patient who has taken much opium loses her 
power of bearing pain, and when to the slight discom- 
fort is added the craving for the drug, she can not or 
will not distinguish between the two sensations, and 
calls loudly for the opiate. If it is withheld, the need 
of it ceases after a while. Of course, if the patient is 
a confirmed opium-taker, the task of weaning her from 
the habit becomes the more difficult. 

As a substitute for opium, recourse may be had to 
external applications, to atropia, hyoscyamus, conium, 
and cannabis Indica ; subcutaneous injections of water 
will sometimes be of advantage. 

Bromide of potassium and chloral had better be 
used only occasionally. If their use is habitual, the 
result is bad. Sleeplessness can be remedied often by 
massage, by exercise, by healthy occupation of the 
mind, by removing digestive disturbances, sometimes 
by a meal or a slight stimulant given at bed-time. Care 
should be exercised in using alcoholic stimulants, as 
hysterical patients easily acquire a craving for such. 

During an emotional attack, various preparations of 
valerian, asafcetida, musk, etc., can be given ; yet they 
are by no means always successful. Inhalations of 
nitrite of amyl, ammonia, and ether can be tried. 

The convulsive attacks can sometimes be cut short 
by a command given in a sudden and authoritative man- 
ner ; at other times a slap, or a glass of water thrown 
in the face, may stop the attack. There are some ob- 
jections to this procedure, especially as the water wets 
both patient and bed. In hystero-epilepsy, compression 
of the ovary will almost always cut short the attack ; 
the compression must be directed toward the ovary, 
and be quite strong. 



HYSTERIA. 369 

An ice-bag placed over the hypersesthetic ovary for 
half an hour, or longer, morning and evening, may 
have a beneficial effect in diminishing the frequency of 
convulsive attacks. Blisters may produce a similar 
effect. 

Fere has caused an ovarian compressor to be made 
which can be worn by the patient ; this causes the at- 
tacks to be postponed. Inhalation of ether may cause 
the attack to cease. 

An indifference to attacks, in which the patient does 
not lose consciousness, is a useful means of diminish- 
ing their frequency and their violence, while too much 
curiosity an^L attention will cause the attacks to be 
more frequent and more severe. 

The question of removal of the ovaries has been 
somewhat discussed. Several cases of recovery have 
been reported. The operation should be kepfr in mind 
with reference to severe intractable cases where there 
is evident disease of the organs. 

The phenomena called metallotherapy are of con- 
siderable interest. In some cases of hystero-epilepsy, 
if a metal disk is bound upon an anaesthetic part, in 
ten to twenty minutes sensation returns ; the return of 
sensation is preceded or accompanied by a pricking 
sensation. The return of sensation is not confined to 
the area covered by the metal, but extends beyond the 
disk, mostly parallel with the axis of the limb, if the 
metal is on a limb. Patients are not all susceptible to 
the same metal ; one may be influenced by iron, an- 
other by copper, another by lead, and so on. 

When sensation returns in a part of the anaesthetic 
side in consequence of the application of metal, it will 
be found that a corresponding spot of skin on the 
sound side has lost its hyperesthesia. 

There may be a similar transfer of muscular power, 
of vision, of hearing, taste, and smell. The circula- 
tion is affected, and the temperature may be altered. 

When the metal disk is removed, the anesthesia, 

24 



370 UNCLASSIFIED. 

etc., oscillates for a short time between the two sides, 
until finally the parts recover their previous condition. 
Only a small proportion of the patients affected receive 
any permanent benefit from these applications. 

Burq first, in recent times, called attention to this 
influence of metals. Charcot, his pupils, and many 
others, have followed up these investigations. Many 
curious and interesting facts have been learned which 
can not be given here. 

Among agents which have been experimented with, 
and which may be used with some benefit, especially 
in hystero-epilepsy, may be mentioned the magnet, the 
application of which, to the skin, causes a transfer of 
sensation. Static electricity, in the form of direct dis- 
charges, or discharges from Ley den jars, will cause a 
transfer ; prolonged static baths are said to have a per- 
manent effect. 

The application of both the galvanic and inter- 
rupted currents are often of value. The application 
may be made to the affected parts : if there is anaes- 
thesia, the wire brush to the skin ; if paralysis, the 
skin should be moistened, so that the electricity can 
pass through to the muscles. Beard and Rockwell's 
method of general electrization may be used ; the 
feet of the patient are put in a basin of water (not a 
metallic basin), in which one pole is placed ; the other 
pole may be passed over the patient's neck and shoul- 
ders, or may be placed in another basin of water, in 
which his hands are dipped. 



CHAPTER XXXII. 

15TEUKASTHENIA. 

Mitchell, S. Weir, Fat and Blood. Philadelphia, 1884.— 
Beard, G. M., A Practical Treatise on Nervous Exhaustion. New 
York, 1880. — Mitchell, Lectures on the Diseases of the Nervous 
System. Philadelphia, 1881.— Playp air, W. S., The Systematic 
Treatment of Nerve-Prostration and Hysteria. London, 1883. — 
Clark, F. le Gros, Some Remarks on Nervous Exhaustion and 
on Vaso-Motor Action. Jour, of Anat. and Physiol. , April, 1884, 
p. 239. 

Neurasthenia means simply an exhaustion, and con- 
sequent weakness, of the nervous system in general. 
During the last few years this condition has attracted 
much attention, and has been looked upon as a sepa- 
rate, independent affection. Beard led the attention 
in recent years to the many various disturbances which 
can be classed under this head. 

JEtiology. — The causes of neurasthenia are very 
numerous, the most important, perhaps, being the mode 
of life, habits, and customs of the present generation. 

Heredity certainly plays an important part in the 
aetiology, many of the patients having a father or moth- 
er, or both parents, similarly affected, or suffering from 
some debilitating disease, as phthisis. Women are the 
most subject to the disease, although men are by no 
means exempt. 

Of other causes, the training which the child re- 
ceived in its infancy and early years acts powerfully ; 
the school-life and the home-life both aid in develop- 
ing a weakened nervous constitution. In adult years, 
the wear and tear of business and of social life, the 



372 UNCLASSIFIED. 

anxieties and worries, the disappointments frequently 
met in the struggle for existence, aid also in the same 
direction. The way houses are built, the way they are 
warmed and ventilated, habits in regard to diet, in re- 
gard to sleeping, exercise, employment, and amuse- 
ment, must be reckoned as favoring the development 
of this affection. To go into particulars would require 
an enumeration of every violation of the laws of health 
and hygiene which are so common at the present time. 

Pathological Anatomy. — There is probably no 
special pathological change to be discovered on inspec- 
tion, or the minutest examination of the nervous sys- 
tem. In the vast majority of cases the disturbance is 
purely functional, at least in the commencement. In a 
few cases there is a strong suspicion or probability 
that the nervous exhaustion leads finally to structural 
changes, as sclerosis ; this is, however, by no means 
positively proved. Most patients, however, have an 
unhealthy complexion. There is an expression about 
the eyes and mouth which is characteristic. The gait 
and other movements of the patient are also more or 
less characteristic of the languor and discomfort expe- 
rienced. These peculiarities can not be well described, 
but can be learned by observation. 

Symptoms. — A patient usually comes only gradu- 
ally to realize that his health is impaired. 

The first symptoms are those of languor, of disin- 
clination for exertion. The patient finds it necessary 
to rouse himself by an effort of the will to perform his 
daily duties. This languor and lassitude may be ac- 
companied with more or less discomfort in the head, 
perhaps amounting to pain ; or there may be a sense of 
weakness across the back, and pain along the spine. 
Sometimes there are various abnormal sensations in the 
limbs. 

Attending the pain in the head or back, there is 
usually more or less tenderness on pressure over the 
scalp, or the spinous processes of the vertebrae. The 



NEURASTHENIA. 373 

back of the head and upper part of the neck are very- 
likely to be the seat of the pain. This tenderness may 
be excessive. This is the condition which has been 
called "spinal irritation." It is often attended with 
motor and sensory disturbance of the limbs, according 
to the level at which it may be. There is no need to 
raise this symptom to the dignity of a separate affec- 
tion ; it is merely the result of the general nervous ex- 
haustion localized. 

Noises in the ears, of various kinds, may also be 
noticed. The pupils may be widely dilated, or have an 
unusual mobility. 

Loss of sleep is sometimes very distressing ; the pa- 
tient may find it difficult to get asleep, and lie awake 
half the night, or he may have no difficulty in dropping 
to sleep when he first goes to bed, but, waking up after 
an hour or two, lies awake for several hours. Some- 
times, when the sleep seems to be sound during the 
whole night, the patient awakes unrefreshed, feeling as 
tired as when he went to bed. It is no uncommon 
thing to have the patient feel sleepy before going to 
bed, unable to do anything on account of the extreme 
drowsiness, and then, on retiring, he is as wide awake 
as possible. 

When the disturbance has continued some time, 
and advanced considerably, there may be an irritability 
of temper and a change of disposition, which renders 
it very trying to get along with such patients. He may 
be unable to control his mental operations. Reading 
even a few sentences is fatiguing, or it is impossible to 
understand anything that is read, so that all intellect- 
ual work must perforce be abandoned. 

Various disturbances of the secretions, either a de- 
ficiency or an increase of perspiration, or of the saliva, 
or of urine, show that the secretory functions are inter- 
fered with. Many patients cry very easily in a hys- 
terical manner. 

The voice may be changed and peculiar. A com- 



374 UNCLASSIFIED. 

plaining, weak, high-pitched voice is sometimes met. 
The vaso-motor system shows a certain amount of in- 
stability. It is common for patients to blush easily on 
the slightest provocation. There is also frequently a 
sensation of heat, flushing of the face and head, which 
at times is extremely disagreeable, almost painful. This 
sense of heat may also be experienced through the back 
and limbs, and alternate with chills creeping over the 
body. 

Perhaps, owing in part to the instability of the vaso- 
motor system, these patients are very susceptible to 
changes of weather ; especially, dull, cloudy, and cold 
weather is found to be disagreeable. Many times, also, 
the heat of summer is oppressive, though the patients 
very often desire the rooms in which they dwell during 
the winter to be kept at a high temperature. The 
strength is very easily exhausted. Having no reserve 
force, if there is an extra demand for exertion they 
find themselves unable to meet the emergency, and 
hence are quickly tired. They may be entirely inca- 
pacitated for the ordinary duties of life, in consequence 
of lack of power for sustained exertion. 

The symptoms in neurasthenia change and vary 
from time to time even in the same patient. There are 
no two patients in whom the group of symptoms is 
the same. Also, the symptoms can not be reconciled 
with an organic change in any part of the nervous sys- 
tem. They are too variable and too contradictory to 
have any such sound basis. Many of these patients 
are more or less hysterical, and it is sufficient that the 
physician should mention symptoms for the patient 
to have them at the next examination. 

Diagnosis. — The diagnosis of nervous exhaustion 
can be made only after a careful study of the symp- 
toms, both subjective and objective. 

The accounts already given of various organic dis- 
eases, with their symptoms, will be sufficient to enable 
any one, after a careful examination, to decide whether 



NEURASTHENIA. 375 

there is any such organic change. If not, and if the 
symptoms are frequently changing, and if the patient 
has a semi-hysterical appearance, seems to be dwelling 
a great deal upon his own symptoms, over -anxious 
about himself, it will be pretty safe to decide that there 
is no organic change, but that the disturbance is simply 
nervous exhaustion. 

Prognosis. — The chances of recovery in these pa- 
tients depends a great deal upon whether the exhaus- 
tion is excessive, and whether the patients have, 
through several years, gradually reached the condition 
in which they are found. 

At the very best, it will require many months, per- 
haps years, for a satisfactory recovery ; and, if the pa- 
tient is somewhat advanced in years, he can never 
regain the vigor of earlier life. Death almost never 
results as a consequence of nervous exhaustion, though 
it is possible that, after several years, organic changes 
may be set up in the nervous system, which may then 
lead to a fatal termination. 

Insanity, especially melancholia, is not very likely 
to occur as the sequel of neurasthenia. Many patients 
neither get well nor grow worse, but live an invalid 
life, suffering greatly, having very little comfort in 
themselves, and feeling that they are a burden and care 
to their friends, until some intercurrent disease ends 
their life. 

Treatment. — One of the first requisites in treat- 
ment of such patients is rest, and many of the patients 
require bodily as well as mental rest. If the disease is 
but slightly advanced, it may be sufficient to send the 
patient away from home to get him out of the regular 
ruts of life, away from business and its cares, or, in the 
case of women, away from household duties and anxie- 
ties, or the excitement of fashionable life. 

Traveling is rarely of benefit. It is better for the 
patient to go to some retired place where recreation and 
amusement can be obtained sufficient to make the time 



376 UNCLASSIFIED. 

pass pleasantly, and, settling down, lie should deter- 
mine to obtain the greatest amount of rest possible. 

In cases where the disease is rather advanced, it is 
much better that the patient should be taken away from 
home, away from the care and the sympathy of friends, 
placed among comparative strangers, and subjected to 
the treatment which Weir Mitchell has so ably de- 
scribed in his two little books. This treatment con- 
sists in putting the patient to bed, feeding systematic- 
ally at first with milk, and later with other easily 
assimilated food, supplying the place of exercise by- 
massage and electricity. 

These patients usually have much trouble in sleep- 
ing. It may at first be necessary to give various reme- 
dies in order to obtain quiet rest at night. A good dose 
of opium, or occasionally bromide of potassium, may 
be of advantage. The bromide, however, should be 
given in divided doses, beginning about the middle of 
the day, so that the patient will take three doses before 
night. Chloral should rarely be given ; paraldehyde 
in doses of thirty to fifty minims is much better. Vale- 
rianate of zinc, combined with extract of hyoscyamus 
and extract of conium, as in the following prescription : 

]jfc Zinci valerianatis gr. ij ; 

Ext. hyoscyami, ) ' M 

Ext. conn, ) ° 

Ft. pil. 

given three times a day, will sometimes quiet the nerv- 
ous restlessness, and favor sleep better than anything 
else. This combination also has the advantage of be- 
ing slightly laxative. If there is instability of the vaso- 
motor system, flushings, and chills, it may be an ad- 
vantage to combine with this ergot, cod-liver oil, and 
other tonics ; arsenic, iron, strychnia, etc., may be 
given as seems most desirable. 

Electricity is useful, not only to obtain the passive 
exercise of the muscles, but, given in the form of gen- 



NEURASTHENIA. 377 

eral faradization, as described by Beard and Kockwell, 
is often of very great advantage, acting as a general 
tonic ; the static form is also useful. 

It may be well to say a few words in regard to feed- 
ing. Most of these patients are underfed. In many 
there is nervous dyspepsia, and the stomach will bear 
but a small amount of food at one time. It is neces- 
sary, therefore, to feed frequently. Occasionally as 
often as every half-hour a few spoonfuls may be given. 
Milk, or some of the various preparations, as Eidge' s 
Food, or Mellin's Food, can be given at first, but soon 
other things may be joined with it, as has been already 
mentioned in regard to the feeding of patients. 

To carry out a successful treatment of these patients 
requires a great deal of tact and perseverance on the 
part of both the physician and the patient. The pa- 
tient must stay in bed long enough. The mistake is 
more frequently made of not keeping the patients con- 
fined as long as is necessary rather than of keeping 
them in bed too long. 

The methods of treatment while the patient is in 
bed must be changed and varied as circumstances re- 
quire. "Where there is extreme exhaustion, very little 
attention needs to be paid to the amusement or the 
recreation of the patient while thus confined. As the 
patient, however, gains strength, it may be well to al- 
low some reading. After a while the patient may be 
allowed to read a little himself. Then other light em- 
ployments may be gradually taken up ; but it is neces- 
sary to remember that sewing, knitting, crocheting, etc., 
are really a severe tax upon the muscular system, and 
will often of themselves produce pain in the back and 
head, so that it is necessary to limit the time of such 
employment. 

When the patient begins to get up, it will be neces- 
sary to carefully regulate the amount of exercise and 
exertion, in order that he may not overtax himself, and 
so be put back and delayed in recovery. 



378 UNCLASSIFIED. 

Many times it is necessary to confine the patient to 
the bed all day long. He can change from bed to 
lounge, or couch, and back again. At first it may be 
necessary to exclude friends ; but, later, a friend, who 
has the wisdom not to stay too long and not talk too 
fast or much, and who does not tire the patient, may 
be admitted as may seem most desirable. 



CHAPTER XXXIII. 

TETANUS AKD TETANY. 

Aufrecht, Zur pathol. Anatomie des Riickenmarks beim Te- 
tanus. Deut. med. Wochen., No. 14, 15, 1878, and London Med. 
Bee., June 15, 1878, p. 238.— Coats, J., On the Pathology of Tet- 
anus and Hydrophobia. Med.-Chir. Trans., 61, 1878, p. 79. — 
Woods, G-. A., A Contribution to the Pathology of Tetanus. Lan- 
cet, Sept. 7, 1878, p. 326.— Wood, H. C, Abstract of a Lecture on 
a Case of Idiopathic Tetanus. Philadelphia Med. Times, March 
15, 1879, p. 273. — Knecht, Beitrage zur Lehre vom Tetanus. 
Schmidt's Jahrb., 181, 182, 1879.— Macdougall, J. A., The eti- 
ology of Tetanus, etc. Lancet, July 19, 1884, p. 98.— Bowlby, A. 
A., Five Cases of Tetanus, with some Remarks on its Pathology. 
St. Barth. Hosp. Bep., 1883, p. 85. 

Tetany. — Trousseau, Lectures on Clinical Medicine. New 
Syden. Soc, 1868, vol. L— Erb, W., Zur Lehre von Tetanie. 
Arch. f. Psych., iv, 1874, p. 271.— Chvostek, Beitrag zur Tetanie. 
Wien. med. Presse, 1876, 1878, 1879.— Weiss, N., Ueber Tetanie. 
Volkmann's Sammlung, No. 189, 1881.— Gowers, W. R., Clini- 
cal Lecture on Tetany. Lancet, July 21, 1883, p. 92. 

TETANUS (Locked- Jaw). 

Tetanus is a continuous tonic spasm of the muscles, 
due to an increase of the reflex irritability in conse- 
quence of an injury, though sometimes apparently the 
result simply of a chill. 

JEtiology. — Injuries of the extremities are more 
frequently the cause of tetanus than those of the trunk. 
Both severe and slight wounds may be followed by the 
spasms, which may occur before the wound is healed, 
or only a long time afterward. 

Exposure to the inclemency of the weather, and 
various hardships, also lack of cleanliness in the care 



380 UNCLASSIFIED. 

of the wound, are more likely to be associated as causes 
of the attack. 

The disease is somewhat common in military sur- 
gery, and the soldiers of the vanquished party are more 
likely to be affected than the victors. In civil life, men 
are more commonly affected than women, being more 
exposed to injuries. 

The disease is very common in certain countries in 
new-born children, especially during the first nine days 
of life. 

Children are more likely to be affected in warm cli- 
mates ; and there are also districts in temperate zones 
where the disease is more likely to occur, as along the 
southern and eastern shore of Long Island. 

It is said that the colored races are more likely to 
be attacked than whites. 

Symptoms. — The first symptom is usually a stiffness 
of the jaws (trismus), which renders it somewhat diffi- 
cult to open the mouth. Then there is a slight spasm 
in the muscles of the neck, and later this spasm ex- 
tends to the muscles of the back and of the trunk. 
The severity of the contraction steadily increases, and, 
the extensors being the most powerful, the body is gen- 
erally drawn backward, so as to form an arch, and, 
when the spasm is extreme, the patient rests upon his 
head and heels, the body being arched above the bed 
(opisthotonus). 

The arms and hands are often unaffected, though 
they may be rigid in extension. 

The contraction of the muscles is attended with se- 
vere, cramp -like pains, producing extreme distress. 
The skin is frequently covered with perspiration dur- 
ing the spasm. The contraction of the respiratory 
muscles interferes with breathing, so that at the height 
of the spasm the patient has a sensation of impending 
suffocation. Owing to the closure of the jaws, the-pa- 
tient finds great difficulty in speaking, and it is almost 
impossible to feed him. 



TETANUS. 381 

The muscles are continuously in a state of contrac- 
tion, but are not always contracted to such an extreme 
degree, remissions occurring, during which the patient 
may resume the ordinary position in bed, be able to 
take food, and converse ; yet the slightest irritation, 
even breathing upon the patient, or a slight jar of the 
room, or an attempt to swallow, will cause a recurrence 
of the extreme spasm. 

The temperature is but little affected except just be- 
fore death, when it may rise as high as 112° or 113°. 
The pulse, also, is nearly normal, except toward death 
it may, with the rise of temperature, become very rapid. 

The mind is usually unaffected, except toward the 
close of life, when there may be delirium. Occasion- 
ally the patient dies in consequence of the disturbance 
of respiration ; but this is not very common. Many 
times the patient dies in the interval between the 
spasms, apparently worn out by the disease. 

Pathological Anatomy. — The pathological changes 
found in tetanus do not explain the symptoms, nearly 
all being apparently the effects of the disease rather 
than the cause. 

In many cases, however, inflammation of the nerves 
leading from the seat of the wound have been recog- 
nized, and occasionally there have been found changes 
in the spinal cord, the blood-vessels being surrounded 
by leucocytes. Ross mentions finding these bodies 
in the gray and white substance, around the vessels, 
though not usually aggregated in the perivascular 
spaces, as in hydrophobia. He also found some changes 
in the ganglion -cells of the anterior cornua. 

Diagnosis. — It is scarcely possible to mistake teta- 
nus when well marked. 

It is important to make a diagnosis as early as pos- 
sible, even when there is only the first symptom of tris- 
mus. 

Strychnia-poisoning resembles tetanus in some re- 
spects, but the spasms are less continuous, having pe- 



382 UNCLASSIFIED. 

riods of entire intermission ; also the reflex irritability 
is somewhat less marked, and the disease begins more 
abruptly, affecting the limbs first rather than the mus- 
cles of mastication and the neck. 

Prognosis. — The disease is always a grave affection ; 
seventy per cent or more die. 

It is less serious when the result of cold than when 
there has been a previous wound or injury. The longer 
the time after the injury when the first symptom ap- 
pears, the more favorable the prognosis. Infants al- 
most always die. 

Treatment. — The patient should be put in a dark 
room, kept as quiet as possible, and every possible effort 
made to prevent any impressions which would excite 
the spasm. One of the most difficult problems is how 
to feed the patient. It is absolutely necessary to keep 
up his strength, and the feeding should be done, in the 
most quiet way, with liquid nourishment, so as to re- 
quire as little effort on the part of the patient as pos- 
sible. 

The jaws being closely locked, it may be necessary 
to pass the food in by a tube behind the teeth. It has 
been recommended to feed the patient, while under the 
influence of ether, by means of a tube passed through 
the nostril into the stomach. 

Of antispasmodic drugs, almost all in the Pharma- 
copoeia have been used at different times. Curare and 
calabar-bean have been used to diminish the reflex irri- 
tability. Chloral and bromide of potassium together 
are of great advantage, but it is necessary to give large 
doses. As high as sixty grains of chloral have been 
given, repeating it as may be necessary. Generally, 
twenty or thirty grains, with the same amount of bro- 
mide of potassium, given every two or three hours, 
would be sufficient. Thompson gave three grains daily 
the first three days, ten grains daily the next ten days, 
five grains daily the next seven days, after that gradu- 
ally reducing the quantity so that in twenty-six days 



TETANY. 383 

one hundred and thirty-three grains were taken, the 
patient being a child seven years old. 

Read gave twenty drops of gelsemium every two 
hours, and the next day forty drops every two hours, 
the patient recovering. 

The patient may be kept under the influence of 
ether, so as to prevent the spasms, when other means 
fail. 

Various surgical expedients have been tried; the 
nerves have been divided above the seat of the wound. 
Unless this is done very soon after an injury, it would 
probably have but little influence. Stretching the 
nerve leading to the wound has proved of benefit in a 
few cases. 

TETANY. 

Tetany has been sometimes spoken of as intermit- 
tent tetanus, sometimes as an intermittent cramp. It 
consists of spasms affecting more generally the upper 
extremity, in severe cases extending also to the legs 
and body, intermittent, recurring at irregular inter- 
vals. 

Symptoms. — Trousseau speaks of three varieties, 
the mildest, which is local in its manifestations, being 
confined to the extremities, usually the upper, some- 
times affecting the lower. The spasm consists chiefly 
in a partial flexion of the fingers, the thumb and fin- 
gers being approximated so as to form a cone. The 
wrist is flexed and pronated and the forearm flexed 
upon the wrist. In the lower extremities, the toes are 
flexed, the foot and leg extended. 

The spasm is attended with severe pain, and any 
effort to overcome it is painful. 

The convulsions may last for from five to fifteen or 
twenty minutes ; the less severe convulsions may con- 
tinue two or three hours. 

These attacks may be repeated once a day, or sev- 
eral times a day, for several months, and then the pa- 



384 UNCLASSIFIED. 

tient may be entirely free, until after some months the 
attacks reappear. One of my patients had these at- 
tacks regularly twice a year, lasting each time three 
months. 

Trousseau has mentioned that in the interval be- 
tween the spasms a compression over the track of the 
nerves or the vessels will cause the attack, which con- 
tinues as long as the compression is maintained, ceas- 
ing as soon as the pressure is removed. 

After the attack there is for a short time loss of 
power in the limbs affected. Sensation is likely also 
to be diminished. 

Trousseau's middle form of the disease combines 
with the spasms already mentioned other general 
symptoms, which he mentions as feverishness, head- 
ache, loss of appetite, slight congestions in different 
parts of the body ; the spasms are more severe, return 
more frequently, and affect the muscles of the trunk 
and face, as well as those of the extremity. He has also 
enumerated a third and more grave form of the disease, 
which differs in nothing from the other except in being 
more severe. 

Sometimes the patients recognize that an attack is 
approaching, by unpleasant sensations in the hands and 
feet, and slight stiffness in moving. 

Several authors have recognized a very great in- 
crease of electrical irritability in both the nerves and 
muscles of the affected limbs during the attack. 

The disease is of long duration when once it appears, 
extending, with the intermissions, through many years. 

^Etiology. — Very little is known as to the cause of 
this disease. " Catching cold " is often mentioned as 
the starting-point of the spasms. Various exhausting 
influences seem to act as causes. One patient stated 
that eating and drinking would bring on an attack dur- 
ing the time when he was liable to have them. 

Pathological Anatomy. — Very few autopsies have 
been made, and but little is known as to the changes in 



TETANY. 385 

the nerves or their centers. Weiss found swelling of 
the ganglion- cells of the anterior cornua, with a lateral 
position of their nuclei and vacuoles in the cells and 
their processes ; also atrophy of the cells, with loss of 
their protoplasmic processes. 

Diagnosis. — The character of the spasm, the inter- 
mission of the attacks, and especially Trousseau's ma- 
noeuvre of pressing upon the nerve or vessel of the limb, 
are sufficient to determine the nature of the disease. 

Prognosis. — The disease is rarely fatal, though a 
few cases of death have been reported. The patient, 
having passed through one attack, is not safe from sub- 
sequent attacks. 

Treatment. — It seems as though very little could 
be done to cut short the spasms. Opium, belladonna, 
chloral, and inhalations of ether may be used as indi- 
cated. 

Electricity may be tried, either by faradizing the 
muscles that are not affected, or the use of galvanism 
to the nerve-centers. 

Erb saw a recovery take place from the stabile ap- 
plication of the anode to the vertebral column and 
the nerve-trunks chiefly affected. I used electricity in 
one case in every way I could think of, without a par- 
ticle of benefit. I have obtained more benefit from the 
use of the fluid extract of conium, twenty drops every 
two hours, than from any other remedy. Between the 
attacks, quinine, arsenic, and valerianate of zinc, and 
other nerve-tonics, should be given. 



CHAPTER XXXIV. 

MYXCEDEMA. 

Ord, On Myxoedeina. Med.-Chir. Trans., lxi, 1878. — Cushier, 
Elizabeth, M., A Case of Myxoedema. Archives of Med., Dec, 
1882, p. 203.— Oliver, T., Clinical Lecture on Myxoedema. Brit. 
Med. Jour., March 17, 1883, p. 502.— Edes, R. T., Clinical Lecture 
on a Case of Myxoedema. Boston Med. and Surg. Jour., April 
24, 1884, p. 385.— West, E. G., A Case of Myxoedema, with Au- 
topsy. Boston Med. and Surg. Jour., July 17, 1884, p. 50. 

Myxoedema consists essentially in an increase of the 
subcutaneous tissue, which is infiltrated with mucin, 
so that the general appearance is that of oedema, yet 
the skin does not pit on pressure. 

Symptoms. — The patient's appearance is very pecul- 
iar. The eyelids are thick, as if swollen with crying, 
or infiltrated with serum ; the nose is very broad, the 
lips thick, the hands are large and misshapen, the fin- 
gers being club-shaped. The feet are usually affected 
the same as the hands ; the swelling sometimes extends 
to other parts of the body, especially to the arms and 
legs, and even to the trunk itself. The tongue is usu- 
ally very much swollen. The patient has many times 
a waxy or anaemic complexion, the red-blood corpuscles 
being diminished in number. The infiltrated tissue has 
a semi-translucent appearance. 

The motions are necessarily slow and difficult. The 
patient manages his large fingers in a clumsy way, so 
that the more delicate manipulations of writing or sew- 
ing are illy performed. The gait of the patient in walk- 
ing is slow, as if great exertion were required. 

Ordinary sensation is diminished, and the special 



MYXCEDEMA. 387 

sensations of taste and smell may also be diminished, 
probably on account of the swelling of the mucous 
membrane of the nose. 

In some cases the temperature has been noticed to 
be above normal, but it is usually diminished. The 
pulse is generally slow. 

In most of the cases observed the intelligence has 
seemed to be affected. The patient answers questions 
slowly, as if it were an effort to think or speak. She 
seems indifferent to her surroundings. Memory may 
be weakened. The simplest operations of arithmetic 
are performed with difficulty, or the patient is unable 
to give correct answers. 

Sometimes the hair falls out. The nails become 
brittle and furrowed. 

The digestion is affected only when the disease has 
reached an extreme degree. 

Constipation is very common. Menstruation is often 
irregular. In some cases the thyroid gland has been 
very much diminished in size. 

The succession of these symptoms may vary some- 
what in different cases. Sometimes the mental depres- 
sion, even reaching the degree of melancholia, may ap- 
pear early ; or, on the other hand, there may be a very 
great amount of swelling, with the mind almost entirely 
unaffected. 

^Etiology. — The causes of this disease are very ob- 
scure. In several cases worry or anxiety, or some men- 
tal shock, has preceded the attack. We, however, in 
fact, know almost nothing in regard to the real cause 
of the affection. 

The course of the disease is very slow, most of the 
cases extending over several years. 

Pathogenesis. — The nature of this disease is as 
yet imperfectly known. On the one hand, it is sup- 
posed that the changes in the skin are primary, and 
that, owing to defective sensation, the cerebral disturb- 
ance follows as a result of the cutaneous change. 



388 UNCLASSIFIED. 

Another view is that the disease is due to disturb- 
ance of the nervous system, either the sympathetic or 
a more general disturbance involving other than the 
sympathetic system, and the cutaneous changes are 
looked upon as secondary. 

In the few autopsies which have been made, the ex- 
amination has not been, as a rule, complete ; in each 
case some important parts were overlooked, and not ex- 
amined. Changes have been found in the spinal cord, 
in the blood-vessels, and nerve-cells. 

Dr. E. M. Cushier ("Archives of Medicine," 1882, 
p. 216) says: "The disease in question can only be 
described as a nutritive disturbance, resulting in the 
presence, in the connective tissue, of a substance com- 
mon in embryonic tissue, but not existing normally, ex- 
cepting in very small amounts, in adult life." 

Teeatment is comparatively unsatisfactory ; almost 
every means of arresting the progress of the disease 
has failed. A few cases have been reported in which 
the use of tonics, such as iron, quinine and strychnia, 
warm-air baths, massage, and general hygienic treat- 
ment, have seemed to be of some advantage. The dou- 
ble chloride of gold and sodium has been recommended. 
Dr. Edes refers to a curious case, in which abdominal 
dropsy occurred, and became so severe as to require 
tapping, after which operation both the ascites and 
myxcedema disappeared. 



CHAPTEE XXXV. 

TOXIC NEUROSES. 

Lead.— Bernhardt. Arch. f. Psych, u. NervenJc., iv, 1874, p. 
601.— Westphal, C. Ibid., p. 776.— Riegel, F. Deut. Arch. f. 
Tel. Med., 1878, p. 175.— De Watteville, A. Lancet, July 10, 1880, 
p. 44.— Monakow. Arch. f. Psych., x, 1880, p. 495.— Zunker. 
Zeitschr.f. M. Med., 1880, p. 496.— Birdsall, W. R. Amer. Jour, 
of Neurol, and Psych., May, 1882, p. 176.— Webber, S. G. Arch, 
of Med., Aug., 1882.— Putnam, J. J. Boston Med. and Surg. 
Jour., 1883, p. 315. 

Arsenic. — Seeligmuller, A. Deut. med. Wochenschr., No. 
14, 1881.— Popow, N. St. Petersb. med. Wochenschr., 1881, p. 
311.— Da Costa, J. M. Philadelphia Med. Times, March 26, 
July 2, 1881.— Mills, C. K. Med. News, March 3, 1883, p. 257. 
— Seguin, E. C. Jour, of Nerv. and Mental Dis., Oct., 1882 ; 
Opera Minora, 1884. 

Alcohol.— Hutchinson, J. E., Symptoms and Treatment of 
Alcoholism. Phila. Med. Times, July 30, 1881, p. 687.— Pepper, 
William, On Acute Diseases in Drunkards — Delirium Tremens. 
Phila. Med. Times, June 17, 1882, p. 621.— Atkinson, F. P., The 
Treatment of Delirium Tremens. Practitioner, Jan., 1883, p. 38. 
— WlLLE, Ueher einige klinische Beziehungen des Alcoholismus 
Chronicus. Zeitschr. f. Psych., 1884, Bd. xl, p. 827. 

Hydrophobia.— Benedikt, M., Zur pathologischen Anatomie 
der Lyssa. Virch. Arch., Bd. lxiv, 1875, p. 557 ; Bd. lxxii, 1878, 
p. 425. — Bollinger. Ziemssen's Cyclop., Am. Trans., vol. iii, 
1875.— Curtis, T. B., A Case of H. Boston Med. and Surg. Jour., 
Nov. 7, 1878, p. 581 et seq.— Putnam, J. J., The Physiological Pa- 
thology of the Hydrophobic Paroxysm. Ibid., Nov. 21, 1878, p. 
650.— Gowers, W. R. Ibid., Feb. 6, 1879, p. 178.— Foot, A. W., 
Report on H. Dublin Jour. Med. Sci., Oct. 1, 1879, p. 287.— Col- 
lins and Mills, C. K., Cases, with Microscopic Report. Proc. 
Phila. Co. Med. Soc, 1880, ii, pp. 107, 117.— Colin, L., Annales 
d'hygien pub. May, 1881, p. 408.— Ruxton, John, A Case of Hy- 
drophobia ; Recovery. Brit. Med. Jour., Nov. 19, 1881, p. 811.— 



390 UNCLASSIFIED. 

Broadbent, Cases of Supposed Hydrophobia treated by Chloral, 
one of which recovered. Med. Times and Gaz., March 17, 1883, 
p. 308. 

CHRONIC LEAD-POISONING. 

Lead may be taken into the system through the 
skin, by the mouth with food, or, inhaled as dust, may 
be swallowed with the saliva. The occupations in 
which lead is used are readily recognized in most cases ; 
among those less known as dangerous may be men- 
tioned file-cutters, brush-makers, workers in enamel, in 
colored papers, in lace, and in rubber-factories. 

Food preserved in tin, or drink passing through 
lead pipes, or stored in lead-lined cisterns, not only or- 
dinary drinking-water, but mineral-waters, ale, beer, 
etc., are likely to contain lead. 

Symptoms. — The time when the symptoms appear 
after exposure varies from a few days to several years. 

Ancemia is one of the earliest and most common 
effects of lead. The red corpuscles may be reduced 
one third in number ; their size is also slightly in- 
creased. The patient is sallow ; the skin is dry and 
harsh, sometimes oedematous. A narrow line of bluish- 
purple color may be frequently noticed at the edge of 
the gums in patients who do not cleanse their teeth. 

Lead colic is a well-known symptom. Preceding 
the attack, the appetite may have failed for some days, 
there may have been a sweetish or disagreeable me- 
tallic taste, and a general feeling of ill-ease. Consti- 
pation is usually present. The pain is light at first ; 
gradually increases until it is of extreme severity. The 
spasms of pain are usually of short duration, but recur 
frequently, so as to be almost continuous. The patient 
can not keep quiet ; he tosses about. Generally there 
is no tenderness of the abdomen ; pressure may give 
temporary relief ; nausea and vomiting may occur. 

The pulse is hard ; vascular tension is increased. 
The sphygmograph shows a slight notch at the apex of 



TOXIC NEUROSES. 391 

the curve, a peculiar cupping, by which two points or 
teeth are produced. 

Arthralgia is said to be next in frequency to colic 
as a symptom of lead-poisoning. The pains resemble 
neuralgia ; the joints are somewhat swollen, and may 
be red ; sometimes there are cramp-like pains in the 
muscles. 

The paralysis of lead-poisoning usually affects the 
extensor muscles of the fingers and wrists ; is almost 
always bilateral, though it may begin on one side ear- 
lier than the other. One or more attacks of colic, or 
arthralgia, may have preceded, and there has generally 
been abnormal sensation in the parts, pricking and 
tingling, as if the limb were asleep. The supinator 
longus is rarely affected ; the deltoid is paralyzed rath- 
er than the biceps. The flexors of the fingers always 
seem weak when the extensors are paralyzed. The legs 
are much less frequently affected than the arms ; some- 
times the loss of power is noticed in all four limbs. 
When cosmetics are the cause of the poisoning, the 
muscles of the face may be paralyzed, otherwise they 
are usually exempt. 

The onset of the paralysis is gradual ; sometimes, 
however, a day or two is sufficient to render the hands 
helpless. The muscles undergo atrophy, which may 
be extreme. The electrical reaction is diminished, or 
lost ; the reaction of degeneration may be recognized, 
unless the atrophy has progressed too far. 

There may be partial loss of sensation on one or 
both sides ; this, however, is rare. 

Tremor, resembling paralysis agitans, is occasion- 
ally seen. 

Instead of symptoms of peripheral paralysis, those 
of myelitis may be the only evidence of lead-poison- 
ing. So close is the resemblance that it may be im- 
possible to form a diagnosis from the symptoms alone. 
In order to form a correct opinion, it will be necessary 
to give iodide of potassium, and after a week or so ex- 



392 UNCLASSIFIED. 

amine the urine for lead. Every case of chronic mye- 
litis should be thus examined for lead. 

The severest form in which lead-poisoning shows 
itself is seen when the brain is affected — encephalo- 
pathia saturnina. The symptoms are headache, or 
simply discomfort in the head, incapacity for mental 
exertion, amblyopia and amaurosis, delirium, or even 
maniacal excitement, and epileptiform attacks. Be- 
ginning -with the milder manifestations, the severe 
symptoms may follow within a few days, until a fatal 
termination is reached. 

Many times albumen will be found in the urine, and 
hyaline casts are not uncommon. 

Pathological Anatomy. — Lead has been found in 
nearly all the tissues of the body ; but its presence is 
not constant, and the symptoms do not seem to depend 
thereupon. 

The nerves supplying the paralyzed muscles have 
been found atrophied and degenerated. Changes have 
been found in the nerve-cells of the anterior cornua of 
the spinal cord, also in the vessels of the cord. In 
many autopsies no such changes have been found. 

The muscles undergo fatty granular degeneration. 

Prognosis. — It is very rare for lead colic and arth- 
ralgia to terminate fatally ; relapses, or repeated at- 
tacks, are usual, if the patient continues exposed to 
lead. Lead paralysis is also seldom fatal unless the ex- 
posure to the poison has been very prolonged, and the 
symptoms have been neglected. Under proper treat- 
ment, recovery is the rule ; but many months or years 
may be necessary for restoration of function. 

The prognosis in tremor from lead is favorable. 

When the cerebral symptoms are slight, chiefly 
headache and mental inertia, the chances of recovery 
are good ; the same is true even in cases of delirium 
and mania, though then the prospect is more serious. 
In eclampsia saturnina the patient almost invariably 
dies. 



TOXIC NEUROSES. 393 

Treatment. — It is scarcely necessary to say that 
means should be taken by all workers in lead to pre- 
vent its introduction into the system, or that, with the 
first symptoms of poisoning, there should be yet greater 
care. 

Iodide of potassium should be given to remove the 
lead from the system. During treatment the physician 
must watch lest the liberation of lead from the tis- 
sues should give rise to a recurrence of acute symp- 
toms. 

Warm baths are of value, by maintaining the ac- 
tivity of the skin and favoring metamorphosis of tis- 
sues. Iodide of iron is of value to improve the quality 
of the blood. 

During the attack of colic, morphia should be freely 
used ; it will aid in relaxing spasm, and, with a cathar- 
tic, aid in opening the bowels ; atropia may be com- 
bined with it to advantage. 

Nitrite of amyl inhaled may often relieve the pain 
and shorten the attack ; it also restores the normal ten- 
sion of the vessels aud the normal character to the 
sphygmographic tracing of the pulse. 

To relieve the arthralgia, warm baths, sometimes 
cold packing, and the galvanic current applied locally 
to the affected joint, are of value. Sometimes tincture 
of iodine, though increasing the pain temporarily, may 
give relief subsequently. 

Paralysis should be treated by massage, warm 
baths, and electricity ; the interrupted galvanic cur- 
rent, if the muscles do not react to the faradic. In ob- 
stinate cases, strychnia by the mouth, or subcutane- 
ously, is said to be of advantage ; comparatively large 
doses are required. TJie treatment must be persevered 
in for months or years, and not hastily abandoned. 

In cases where there seems to be myelitis, and in 
cerebral cases, the same course should be pursued for 
eliminating lead. The galvanic current to the head 
will sometimes relieve headache. 



394 UNCLASSIFIED. 

ARSENIC. 

Arsenical poisoning is found among the various ar- 
tificers in that metal ; also among those who use fabrics 
containing arsenic in the dyes, as artificial - flower 
makers, seamstresses, and paper-hangers. Wall-papers, 
cretonnes, etc., bring others in contact with the poison. 

Among some of the more common symptoms are 
disorders of the digestive organs, gastric catarrh, weak- 
ness of the eyes, conjunctivitis, and cutaneous erup- 
tions. A condition of general debility, or even paraly- 
sis, anaemia, and nervous weakness, resembling neu- 
rasthenia, can sometimes be traced to wall-papers 
containing arsenic. 

After acute poisoning by the ingestion of large doses 
of arsenic, when the gastro-intestinal symptoms are 
passing off, those pertaining to the nervous system ap- 
pear. There is first pain in the back and limbs, accom- 
panied with numbness or a sleepy sensation. With 
this, a weakness which increases progressively till there 
is total paralysis. These phenomena occur within a 
week or two after the poisoning. Sensation may be 
almost lost, or scarcely impaired. 

Atrophy of the affected muscles follows, and the 
reaction of degeneration is found. The patellar tendon 
reflex has been found absent, the plantar cutaneous 
reflex absent, while the cremaster reflex was normal. 

The paralysis begins in the legs, and is most severe 
in them ; may also affect the arms, usually in a less de- 
gree. 

Cutaneous trophic and vaso-motor changes are not 
infrequent. In some cases albumen has been found in 
the urine. 

Generally, improvement begins within a month, and 
steadily progresses to perfect or nearly perfect recov- 
ery ; a slight weakness may remain a year after the 
poisoning. In a few cases the paralysis may be per- 
manent. 



TOXIC NEUROSES. 395 

SeeligmuQer gives several diagnostic points : 1. The 
acute origin of the paralysis as contrasted with the 
chronic nature of lead paralysis. 2. The severe sen- 
sory disturbance. 3. Arsenic affects primarily, and 
most frequently, the legs. 4. Atrophy and reaction of 
degeneration appear earlier in arsenical poisoning. 5. 
Other trophic changes are not seen in lead. 

The evidence is sufficient to prove that the symp- 
toms are due to a diffused myelitis affecting especially 
the anterior gray substance. 

Treatment. — It does not seem to be certainly as- 
certained that any special medication hastens the elimi- 
nation of arsenic. As it leaves the system chiefly 
through the kidneys, their action should be main- 
tained, as well as that of the skin, by baths and proper 
clothing. 

Morphia, or other anodynes, may be necessary on 
account of the pain. 

Electricity and massage must be used to restore the 
use of the muscles, as in other affections with similar 
loss of power. 

ALCOHOL. 

The symptoms of acute alcoholism, as seen in sim- 
ple drunkenness, need not be described here. Those 
of chronic poisoning vary considerably. The more 
common effects are a gradually undermining of the 
health and a change in important viscera, as liver and 
kidney, giving rise to diseases of those organs. 

The most common nervous disturbance is found in 
that condition known as delirium tremens. This is the 
final result of a long debauch. Patients vary greatly 
as to the ease with which they have an attack. 

It is the common belief that the sudden leaving off 
of drinking is the cause of delirium tremens. Some- 
times this is so, but many times the patient gives up 
the liquor because he can not take it ; the system will 
not longer tolerate the poison, and then the cessation 



396 UNCLASSIFIED. 

from drinking is the first symptom of the disease, not 
the cause of its outbreak. 

Besides the influence of alcohol, it will be found 
that there has been abstinence from food and loss of 
sleep, aiding to produce the final outbreak of delirium. 
In severe cases, it will be found that patients have not 
slept for a week or more, and have eaten nothing for 
several days. 

Preceding the attack there is a tremor of the hands, 
tongue, and sometimes a general tremor whenever the 
limbs are moved. Vomiting may appear a day or two 
before the delirium. At first there is only an inclina- 
tion to start suddenly ; there is a watchfulness in the 
patient's expression, and he is evidently divided in his 
attention to the physician and his unexpressed fears. 
He fingers the bedclothes with trembling hands. Per- 
haps he is covered with a cold perspiration. The eyes 
are red and watery ; he has a haggard expression. 
After a while the delirium may become more active ; 
various hideous and repulsive shapes present them- 
selves to the disordered brain. The patient starts up, 
and struggles violently to escape from his tormentors. 
Hallucinations of hearing are much less common than 
those of sight. 

It is very seldom that patients ever attempt to in- 
jure themselves or others. If attacks are made upon 
attendants, it is in connection with some hallucination, 
or in an endeavor to escape from imaginary specters. 
So, also, efforts to jump out of windows, etc., are made 
for the purpose of escape. 

The temperature varies ; it is often normal, is some- 
times subnormal, and may be elevated. It is almost 
impossible to take the temperature in an excited pa- 
tient. 

The pulse is rapid and weak where there is much 
excitement, or it may be only slightly increased in fre- 
quency when the excitement is moderate ; it ranges 
from 80 to 150, or even more. 



TOXIC NEUROSES. 397 

Disgust for food, and vomiting of everything taken 
into the stomach, are quite common. 

If the patient does not obtain sleep, the tremor, 
delirium, feebleness of the pulse, and general prostra- 
tion increase until death. Near the^close of life the 
temperature may rise to 106° or 107°. 

A fatal termination is rare if the patient is seen 
early and properly treated, unless there is organic dis- 
ease of one of the important organs. 

Instead of delirium tremens, or after an attack, the 
victims of alcoholism may have serious cerebral symp- 
toms, resembling meningitis, or there may be organic 
disease of the brain ; sometimes there is insanity, usu- 
ally mania, often general paralysis. The prognosis in 
such cases is unfavorable. 

Teeatment. — A quiet room is desirable, with as 
little disturbance from attendants as may be. It is 
better in some cases to have the room darkened ; but 
many times the uncertain, fitful shadows in a dimly 
lighted room disturb the patient more than a bright 
light. His imagination transforms the shadows into 
grotesque or horrible shapes. 

Some authors object to mechanical restraint, advis- 
ing that there should be attendants enough to keep the 
patient quiet and prevent his injuring himself or oth- 
ers. Those who need restraint are excited by the op- 
position of other men ; they will struggle against those 
who, they imagine, are about to injure them. If put 
into a strait-jacket, their struggles soon cease, or are 
much less violent, and there is no danger of injury from 
too great force applied by injudicious, tired, or excited 
(not angry) attendants. Of course, a patient in a strait- 
jacket needs to be watched lest he should work himself 
into a dangerous position, or roll out of bed, or other- 
wise harm himself. If there is vomiting, tincture of 
capsicum should form a part of every prescription ; 
sometimes it is sufficient alone to produce sleep, and 
enable the stomach to retain food. 



398 UNCLASSIFIED. 

If the pulse is very rapid and weak, if there is much 
excitement and tremor, that is, in the worst cases, 
tincture of digitalis, with or without capsicum, is the 
best drug. According to the pulse, from one to four 
drachms should be given. If the pulse is strong and 
only moderately rapid, one drachm, or perhaps half a 
drachm, will be sufficient. In very severe cases the 
larger doses are needed. One dose, sufficient to strength- 
en the pulse, is better than to repeat small doses. Sleep 
may follow in half an hour. The digitalis, not in the 
largest doses, may be repeated after twelve or twenty- 
four hours if it is necessary to procure sleep again. 
Often only one dose is required. It must be kept in 
mind that the patient receives considerable alcohol with 
large doses of the tincture. 

Chloral and bromide of potassium are valuable in 
the milder cases, and in the severer after digitalis has 
reduced the pulse. One or two large doses, thirty to 
forty grains of chloral, with as much bromide, is better 
than repeating small doses frequently. The latter may 
increase the excitement. If the stomach is very irri- 
table, it is better to give only the capsicum by the 
mouth ; chloral, if necessary, can be given by enema. 

Paraldehyde, in drachm doses, may be sufficient in 
very mild cases, or after one or two nights' sleep ob- 
tained by other means. I have not used it in severer 
cases. 

Formerly opium, or its preparations, were generally 
used. In some cases the hypodermic injection of a 
quarter of a grain of morphia is the best treatment. 

After the patient has become quiet, the oxide of 
zinc, two or three grains, or sulphate of quinine, three 
to five grains, given three times a day, will prove most 
useful tonics. 

It is important that the patient should be well fed ; 
at first milk, hot or cold, as best suits the patient, or 
animal broths, are best ; when the stomach will digest 
solid food, it should be given. 



TOXIC NEUROSES. 399 



HYDROPHOBIA.. 



Hydrophobia is always caused by the bite or the in- 
oculation with the saliva of a rabid animal. It never 
arises spontaneously. Domestic animals, dogs, cats, 
cows, etc., and wild animals, as foxes or wolves, may 
communicate the disease. 

About half those bitten are attacked with rabies ; 
bites on unprotected parts, hands, face, and neck, are 
most dangerous. Early cauterization of the wound 
diminishes the danger. Slight wounds, like scratches, 
are more likely to give trouble than severe bites which 
bleed freely. 

There is a stage of incubation, continuing from two 
weeks to five years (Colin), during which the wound 
heals, the patient appears in usual health, though often 
he has a serious apprehension, a dread of the conse- 
quences, which he can not explain. 

Often the first symptom of the approaching attack 
is a pain shooting from the seat of the wound toward 
the nerve-centers ; the cicatrix may become livid. The 
patient's disposition may show a change — he may be- 
come moody or irritable. With or without the above 
symptoms there arises a peculiar difficulty in swallow- 
ing. All the motions can be made, but, so soon as the 
liquid or food touches the mucous membrane of the 
mouth, the irregular or spasmodic action of the throat 
interferes with deglutition. Generally, speech is also 
hindered. 

At first the patient can overcome this irregular ac- 
tion of the muscles, but soon he loses that power, and 
the reflex excitability becomes so excessive that any 
noise suggesting food or drink excites the spasm. Oth- 
er regions also acquire this abnormal excitability, so 
that a slight draught of air over the face, the glitter of 
a bright light on the eye, or a sharp sound heard, has 
the same effect. 

The patient is unable to swallow his saliva, which 



400 UNCLASSIFIED. 

becomes thick, tenacious, and ropy. The irritation 
thus produced gives rise to violent paroxysms ; the pa- 
tient starts up, hurling violently back his attendants, 
clutches at his throat, tries to clear his mouth of the 
mucus, and spits it far from him with extreme violence. 
His whole effort seems to be to expel the saliva which 
so distresses him and interferes with reflex respiration. 

Delirium, hallucinations, and delusions are some- 
times noticeable during these paroxysms, and occasion- 
ally in the intervals. 

After such an attack the patient lies quiet, or may 
sit up at his ease ; can usually walk if desirable. He 
knows when the attack is about to be repeated, and 
may warn his attendants. There is almost never any 
effort to bite or scratch. The stories of patients bark- 
ing like dogs, etc., are in a great degree the products of 
the imagination of attendants. 

Finally, these paroxysms become more and more fre- 
quent, the patient is exhausted by his inability to take 
food, by sleeplessness, and by the violence of the dis- 
ease. Partial paralysis may occur. Death takes place 
either during an attack or quietly in the interval ; the 
power to swallow may return just before death. 

The imagination, or, perhaps, it would be more cor- 
rect to say the emotional conditions and the mental 
influences, seems to exert a great influence over the 
attacks. The sight of water, even a reference to drink- 
ing, will cause one ; yet the same patient may immedi- 
ately after urinate, both seeing the urine and hearing 
it fall into the vessel without any disturbance. 

Diagnosis and Prognosis. — The only affection 
likely to be confounded with hydrophobia is hysteria, 
which in some of its manifestations slightly resembles 
the more serious disorder. A careful observation of 
the patient's condition during the spasm, and in the in- 
terval, will guide to a diagnosis, as will also the experi- 
ment of gently fanning his face, or the manner in which 
he acts when drink is offered, bracing himself for a 



TOXIG NEUROSES. 401 

great effort, seizing the cup, unable to carry it to his 
mouth, or only succeeding in swallowing a few drops ; 
the character of the attack is very different from hys- 
teria. 

There is no resemblance to tetanus, as has been 
sometimes claimed. 

Hitherto death has been the uniform termination, 
except in a few cases, and in many of these the diag- 
nosis is doubtful. 

Pathological Anatomy. — The blood-vessels of the 
brain and spinal cord are distended, their walls are 
thickened, and in many places collections of leucocytes 
surround the smaller vessels, and they may be found 
quite generally scattered through the gray substance. 
Sometimes the blood escapes from the vessels, forming 
small haemorrhages. Ross has found the nerve-cells of 
the median and central groups in the anterior cornua 
shrunken and atrophied ; the spinal accessory and pneu- 
mogastric nuclei were also altered. 

Teeatment. — As soon as one has been bitten by a 
dog, whether thought to be rabid or not, the wound 
should be sucked, either by the person himself or by 
some one else. If the mucous membrane of the mouth 
is unbroken, there is no danger in doing this. As soon 
as possible after this the wound should be thoroughly 
cauterized. Some advise nitrate of silver, others caus- 
tic potash ; the latter is probably the better. The hot 
iron may answer the same purpose, but is less certain 
in its effect, as it can not so surely penetrate to every 
part of the cavity. Gunpowder may be poured into 
or upon the wound and ignited. Or the wound may be 
excised. 

When the first symptoms of the disease have shown 
themselves, there is little chance of recovery. Chloral, 
morphia, and stimulants given by the rectum may re- 
lieve the suffering somewhat. Ether can be inhaled to 
give relief, and while the patient is under its influence 
a tube may be passed into the stomach and food intro- 



402 UNCLASSIFIED. 

duced. Curare and morphia can be injected subcu- 
taneously. Ruxton gave six drops of tincture of can- 
nabis Indica to a boy about six years old each time he 
awoke. The boy recovered. Broadbent reports a cure 
from enemata of twenty grains of chloral, one ounce 
of brandy, and two ounces of beef-jelly every three 
hours. 



CHAPTEE XXXVI. 

SYPHILIS. 

Zambaco, D. A., Des affections nerveuses syphilitiques. Paris, 
1862. — Heubnek, Die luetische Erkrankung der Hirnarterien. 
Leipzig, 1874. — Fournier, A., La syphilis du cerveau. Paris, 
1879. — Savard, P., Etude sur les myelites syphilitiques. Paris, 
1881.— Wood, H. C. Am. Jour. Med. Sci., Oct., 1880, p. 384 ; 
Boston Med. and Surg. Jour., Dec. 20, 1883, Jan. 10, Feb. 28, 
1884.— Lancereaux, E., Syphilis cerebral. Gaz. hebd., 1882.— 
Putzel, L., Syphilis of the Central Nervous System. Med. Rec- 
ord, April 26, 1884, p. 450.— Seguin, E. C, The American Method 
of giving Potassium Iodide, etc. Archives of Med., Oct., 1884. 

Syphilis of the nervous system belongs to the ter- 
tiary period. The first symptoms may appear as early 
as two months after infection, or as late as thirty years ; 
generally between three and twenty years after. 

The nervous symptoms are much more frequently 
seen after a very mild primary attack, and in a large 
proportion of cases there have been no secondary symp- 
toms. So slight has been the earlier manifestations of 
the disease that the patient frequently does not know 
he has had it. 

SYPHILIS OF THE BRAIN. 

Pathological Anatomy. — The changes in the brain 
are similar to those found elsewhere. The membranes 
and vessels are most frequently affected. Gummatous 
tumors form in the membranes, varying in size from 
small grains to the size of a hen's egg ; they are most 
frequent in the pia mater. They are found on the con- 
vexity, and especially at the base near the sella turcica. 



40i UNCLASSIFIED. 

Instead of distinct tumors, there may be a diffusion 
of the new growth over the surface of the membranes 
closely resembling pus, and this may contain small 
gummatous tumors scattered throughout its extent. 

The subjacent cerebral substance is necessarily af- 
fected, partly by spread of the growth destroying the 
nerve-elements, in part by closure of blood-vessels, in- 
terfering with nutrition. 

The syphilitic new growths may undergo degenera- 
tion, and their interior become fatty or caseous. They 
may excite inflammation in their vicinity, acting as any 
other new growth in this respect. 

The arteries are also the seat of syphilitic changes. 
These have been described at length by Heubner. The 
new growth is developed between the elastic lamina of 
the intima and the endothelium. The lumen of the 
vessels is more or less encroached upon by semi-lunar 
segments or zones of the firm, fibrous new formation. 
Sometimes the artery is entirely closed by this process, 
or a thrombus may form at the constricted portion, and 
thus finally effect its closure. 

The brain-substance may be primarily affected ; but 
such cases are rather rare. 

An important peculiarity of syphilitic lesions of the 
brain and its membranes is that they are very often 
multiple ; even distant regions, opposite sides, may be 
simultaneously affected. They may be present an in- 
determinate period, and attain considerable size, with- 
out giving rise to any symptoms. 

Secondary changes, softenings, and inflammations 
are found in connection with these morbid products, 
the same as with those of a different nature. 

Symptoms. — Syphilis of the nerve-centers gives rise 
to no special or peculiar symptoms differing from those 
caused by other lesions of those parts. The diagnosis 
must be made rather from the grouping of the symp- 
toms or other peculiarities in the mode in which they 
show themselves. As in other diseases, the symptoms 



SYPHILIS. 405 

may be divided into those which are due directly to 
the lesion and those which are dependent upon sec- 
ondary changes, which are the same as when these 
changes are dne to other causes. 

Headaclie is the most common and the earliest 
symptom, often the only one. The pain is severe, ob- 
stinate, frequently nocturnal ; it occurs in paroxysms, 
though there may not be entire relief between the at- 
tacks. The scalp or parts of the face may be tender, 
and pressure upon those points may aggravate the pain. 
The severity of the pain is sometimes excessive — ago- 
nizing. Relief is obtained generally only from specific 
treatment ; or, if it seems to follow other means, the 
pain soon returns. Sometimes external periostitis will 
cause a swelling over the cranial bones, which will set- 
tle the diagnosis. 

Pain may also be felt in other parts of the body, in 
the limbs, resembling closely neuralgia from other 
causes. 

With the pain, or independently, the patient may 
have a sense of pressure in the head, dizziness or ver- 
tigo, ephemeral or fugitive attacks of loss of memory, 
dimness of sight, numbness in the extremities, or slight 
impairment of motor power or of speech. These symp- 
toms may be so insignificant that they are ignored until 
questions recall them to the patient' s mind. 

The headache, with or without the above symptoms, 
is of inestimable value as indicating commencing cere- 
bral mischief at a stage when treatment can be of use. 
Though a similar train of phenomena may occur in 
cases of tumor of the brain, in uraemia, and in com- 
mencing meningitis, the possibility of syphilis should 
always be kept in mind, even when patients deny the 
primary or secondary symptoms. 

The motor phenomena, paralysis and S2?asm, are 
characterized by the irregularity of the symptoms, the 
limitation of the paralysis or spasm to a few muscles, 
and their ephemeral or fugitive character. 



406 UNCLASSIFIED. 

Hemiplegia, differing in nothing from that caused 
by cerebral haemorrhage, may occur without special 
warning in syphilis ; but generally the attack is less 
sudden, the paralysis creeping, as it were, from one set 
of muscles to another, the patient not losing conscious- 
ness ; the loss of power frequently does not affect the 
whole side ; is limited to the arm or face, or spares the 
leg. Sensibility is rarely affected. 

Attacks of paralysis of a few muscles or sets of mus- 
cles may appear and disappear several times before 
there is permanent loss of power ; these attacks may 
persist a few hours or days, and be repeated at near or 
distant intervals. 

Spasm, local or general, sometimes precedes the pa- 
ralysis. 

When the prodromic cephalalgia, and other slight 
cerebral disturbances, mentioned above, have preceded 
these paralytic symptoms, there is great reason to sus- 
pect syphilis, and the proper treatment should be fol- 
lowed. 

When individual cerebral nerves are affected, as 
well as the limbs, if the symptoms are irregular, can 
not be accounted for by one lesion, the alternate pa- 
ralysis being such as to show that there must be two or 
more centers of disease, the probability of syphilis is 
greatly increased. 

Among the cranial nerves most likely to be para- 
lyzed may be placed, first, the third nerve, the motor 
oculi ; the sixth, the abducens, is next ; the seventh, 
twelfth, the second, eighth, and fifth follow next in 
frequency. 

Paralysis of the third nerve from syphilis is often 
partial ; it may be combined with paralysis of the sixth 
or not; whether alone or in connection with disturb- 
ance of other cranial nerves, there is reason in such 
cases to suspect syphilis, and careful inquiry for pro- 
dromic symptoms may add to this probability. 

It is unnecessary to describe minutely all the vari- 



SYPHILIS. 407 

ous combinations which are frequently found in such 
cases. 

Spasm or convulsion limited to a few muscles, as the 
facial, or those of one arm, of the hand — monospasm, 
as it is called — is an indication of irritation of the motor 
centers in the cortex of the brain. Very often the le- 
sion in these cases is syphilitic. The convulsion may 
extend to the whole of one side, or it may begin in one 
region and extend to the opposite side, becoming gen- 
eral. Many times consciousness is preserved, or it may 
be only partially impaired. Sometimes severe pain 
in. the head or in the affected limb may attend the 
spasm. 

Convulsions, differing in no respect from true epi- 
lepsy, may be due to syphilis. If the patient is some- 
what advanced in age before the attacks commence, 
their syphilitic origin is the more probable. If mental 
impairment appears early, and motor weakness follows 
the attacks, limited to one side or one limb, and per- 
sisting between the attacks, the probability of syphilis 
is the greater. 

- Sometimes the mental phenomena are most promi- 
nent ; intellectual weakness, loss of memory, inability 
for consecutive thought, delirium, perhaps mania, may 
be present. Sometimes the mental disturbance will 
closely resemble general paralysis. 

While the above symptoms, or groups of symptoms, 
individually only give rise to a suspicion of syphilis, 
the combination of two or more of the groups increases 
the certainty of the diagnosis. 

The course of cerebral syphilis, if not properly 
treated, is steadily downward. The symptoms increase 
in severity, the spasms become more frequent, the pa- 
ralysis extends, and the mental powers are gradually 
lost. Within a comparatively short time a fatal termi- 
nation closes the scene. 



408 UNCLASSIFIED. 

SYPHILIS OF THE SPINAL CORD. 

The membranes are most frequently the seat of the 
morbid changes, the cord being affected secondarily. 
Sometimes the medullary substance itself is attacked, 
the lesion being generally diffused throughout the part 
of the cord which is the seat of the disease. Gumma- 
tous tumors are also found. The bones are less fre- 
quently diseased. The lumbar enlargement is more 
generally attacked than the higher parts. 

The symptoms are very similar to those produced 
by other lesions. When meningitis is present there 
are pains in the back and limbs, perhaps with spas- 
modic action or contraction. The symptoms are vari- 
able ; there may be remissions or intermissions, which 
are not seen in simple meningitis. 

When the cord itself is affected there is more likely 
to be irregularity in the course of the disease than in 
simple myelitis. Locomotor ataxia may be very 
closely simulated. The earlier symptoms may relate 
to the genito-urinary organs. Impotence and inability 
to micturate may precede the paralysis. When the 
Litter appears, it may begin in one leg, and appear in 
the other later. 

Sensation may be unaffected until the paralysis has 
become well marked ; it may be only slightly disturbed 
during the whole course of the disease. In other cases 
both sensation and motion may be lost early. Some- 
times the paralysis pursues an acute course very simi- 
lar to the severest form of ordinary acute myelitis. 

Often the course of spinal syphilis is chronic ; the 
symptoms develop slowly ; there may be periods of re- 
mission, or at least no advance is made. 

The prognosis is unfavorable for complete recovery ; 
if energetic treatment is followed, the symptoms may 
recede and a certain amount of benefit be received ; the 
patient improves, but very often the cord is too serious- 
ly injured for its functions to be completely restored. 



SYPHILIS. 409 



SYPHILIS OF THE NERVES. 

The cranial nerves are the most frequently affected 
by syphilis ; these have been referred to already. Any 
of the other nerves may be implicated in syphilitic 
growths. It is probable that the nerves may be direct- 
ly diseased ; many cases of neuralgia in syphilitic pa- 
tients are probably thus caused. The symptoms seem 
to be very similar to those of neuritis. This depart- 
ment of the subject needs further investigation. 

Hereditary syphilis may attack the nerve-centers ; 
cerebral symptoms are not uncommon ; the spinal cord 
has been the seat of syphilitic changes in very young 
children. 

TREATMENT OF SYPHILIS OF THE NERVOUS SYSTEM. 

There should be no delay in beginning an anti- 
syphilitic treatment. The more serious the symptoms, 
the more energetic this should be. As the brain and 
spinal cord are all-important for life, and as slight 
lesions produce serious permanent disability, it is 
necessary to begin at once with large doses of iodide of 
potassium, and to use mercury freely. 

If the case is very urgent, from forty to sixty grains 
can be given at once three times a day ; if less haste is 
needed, a dose of ten to twenty grains may be given 
three times the first day ; the doses may be increased 
by ten or twenty grains each day, or every other day, 
until some result is obtained. 

Large doses of forty-five to sixty grains are some- 
times borne better by patients than small doses of four 
or five grains. 

The dose should be increased until the disease is 
checked, or there is evident intolerance. What is the 
limit ? Many patients improve when taking one hun- 
dred and twenty grains a day. I have repeatedly given 
two hundred and fifty grains daily, and have even gone 



410 UNCLASSIFIED. 

as high as nine hundred grains a day with no disadvan- 
tage to the patient. 

The drug should be given in a large amount of wa- 
ter ; slightly alkaline water is preferable. It is gener- 
ally better to give it before meals, though with some 
patients it is better after meals, and some prefer to di- 
vide the large doses, taking part before and part after 
meals. 

If the bowels become too loose from the iodide, the 
dose may be slightly reduced, more diluted, and then 
increased more slowly ; or, if there is need for immedi- 
ate effect, a few drops of laudanum can be added to 
each dose. 

Vomiting may seriously interfere with the adminis- 
tration of the drug. If it does, it will be necessary to 
omit it for a while, then begin in smaller doses and in- 
crease more slowly. Or the plan of giving a large dose 
at once might be tried. 

Conjunctivitis, coryza, and glossitis are rare in 
syphilitic patients as effects of the iodide. 

Acne may be met with Fowler's solution, but is not 
a contra-indication to the use of the medicine. 

Mercury may be given by inunction, half a drachm 
or two drachms being rubbed in daily. Internally, the 
biniodide or bichloride is preferable, and should be 
given in doses of from -^ to J of a grain three times 
a day. Many authorities prefer the inunction. 

The iodide of potassium and mercury should not be 
stopped too soon. It is necessary to continue the treat- 
ment several weeks after the patient seems cured. The 
largest dose reached need not be continued. 

Of other treatment, tonics, especially iron and cod- 
liver oil, are generally indicated. The strength should 
be maintained by a generous diet. 

Sequelae and complications should be treated accord- 
ing to the principles given elsewhere. 



INDEX. 



Abscess of the brain, 124. 

Acute ascending paralysis, 192. 

JEsthesiometer, method of using, 2. 

Agrammatism, 48. 

Agraphia, 47. 

Akataphasia, 48. 

Alcoholism, 395. 

Amaurosis in cerebral lesion, 41. 

Amblyopic cerebral lesion, 41. 

Amimia, 47. 

Amyotrophic lateral sclerosis, 252. 

Anaemia of brain, 68. 

acute, 70. 

chronic, 71. 
Anaesthesia, 3. 
Anarthria, 47, 

in lesion of the pons, 45. 

locality of lesion in, 49. 
Angina pectoris, 318. 
Ankle clonus, 9. 

in lesion of spinal cord, 144. 
Aphasia, amnesic, 46. 

ataxic, 47. 

locality of lesion in, 48. 
Apoplexy, 86. 

in multiple sclerosis, 246. 
Arsenic poisoning, 394. 
Arthralgia, lead poisoning, 391. 
Asphyxia, local, of the limbs, 322. 
Ataxia, 46, 141. 

hereditary, 236. 

locomotor, 224. 
Athetosis, 98. 

seat of lesion in, 39. 
Atrophy, facial, 324. 

muscmar, in disease of spinal 
cord, 139. 
Atrophy, muscular, progressive, 207. 

Backache, 148. 
Basedow's disease, 316. 
Bed-sores, treatment, 10. 
Beri-beri, 266. 
Blepharospasm, 300. 



Brain, abscess, 124. 

anaemia, 68. 

anatomy, 18. 

arteries, anastomoses, 32. 

blood-vessels, 31. 

convolutions, nomenclature, 18-21. 

change of blood-supply, 68. 

congestion, 74. 

diseases of, 15. 

exhaustion in cerebral hyperaemia, 
77. 

haemorrhage, 84. 

hyperaemia, 74. 

lesions, destructive, 37. 

lesions, irritative, 37. 

malnutrition (see anaemia), 69. 

membranes, diseases of, 50. 

motor centers, 33. 

physiology, 33. 

sensory centers, 34. 

symptomatology, general, 37. 

syphilis, 403. 

tumors, 116. 

vessels in cerebral hasmorrhage, 
87. 

visual centers, 35, 37. 
Bright's disease in meningitis, 59. 
Bronchial crises, 232. 
Bulbar paralysis, 215. 

acute, 222. 

and muscular atrophy compared, 
219. 

of cerebral origin, 222. 
Burdach, column of, 135. 

Caries of vertebrae, 167. 
Carrefour sensitif, lesion of, 39. 
Caudate nucleus, 21. 

functions, 37. 

lesion of, 39. 
Cavities in brain from thrombosis, 

113. 
Centrum ovale. 19. 
Cephalalgia, 307. 



412 



INDEX. 



Cerebellar peduncle, lesion of, 46. 
Cerebellum, haemorrhage, 46. 

lesion of, 46. 

tumor, 46. 
Cerebral abscess, 124. 

anaemia, 68. 
Cerebral arteries, occlusion of, 107. 

thrombosis of, 112. 
Cerebral haemorrhage, 84, 86. 

diagnosis from embolism, 110. 

explanation of phenomena, 95. 

hyperamiia, 74. 

secpielae, 97. 

softening in embolism, 108. 

tumors, 116. 
Cerebro-spinal sclerosis (see multi- 
ple sclerosis), 242. 
Cheyne-Stokes respiration, 10. 
Chorea, 332. 
Chorea, post-hemiplegic, 98, 335. 

seat of lesion in, 39. 
Clonic spasm, 299. 
Clonus, ankle, 9. 

wrist, 9. 
Compression of spinal cord, 167. 
Compulsory movements. 46. 
Constipation, treatment. 11. 
Contractures after cerebral haemor- 
rhage, 97. 
Convolutions of brain described, 

18. 
Corona radiata, 19. 
Corpus genieulatum, origin of optic 

tract, 27. 
Corpus quadrigeminum anterior, le- 
sion, 43. 

origin of optic tract, 27. 

posterior, lesion. 43. 

striatum, nutrient arteries, 32. 
Cramp, professional. 304. 
Cras cerebri, basis. 22. 

division of fibers in basis, 23. 

lesion of, 42. 

tegmentum, 22. 
Cystitis, 11. 

Degeneration, descending, course of, 

23, 40. 
secondary, in lesion of internal 

capsule, 40. 
Delirium tremens, 395. 
Diet. 13. 

Diphtheritic paralysis, 295. 
Diplegia contraction, 211. 
Diplopia, 3. 
Disseminated neuritis, 266. 

sclerosis, 242. 
Dura mater, inflammation of (see 

pachymeningitis), 50. 



Dynamometer, 5. 
Dysarthria, 47. 

Eclampsia saturnina, 392. 
Electricity, changes in reaction to, 5. 

in testing muscular power, 5. 
Embolism of cerebral arteries, 107. 
Emotions in cerebral haemorrhage, 

99. 
Encephalopathia saturnina, 392. 
Epilepsy, 342. 

diagnosis from cerebral hyper- 
aemia, 80. 
Exophthalmic goitre, 316. 
Eyes, conjugate deviation, 44. 

examination of, 45. 

Face, atrophy of, 324. 
Facial nucleus, lesion of, 217. 
Feeding, methods of, 13. 

by rectum, 14. 
Fibrillary contractions, 210. 
Front tap contraction, 9. 

Gangrene, symmetrical, 322. 
Gastric crises, 231. 
Girdle sensation, 147 
Goitre, exophthalmic, 316. 
Goll, columns of, 134. 
Grand mal, 344. 
Graves's disease, 316. 

Haematomyelitis, 162. 
Haematorrhachis, 159. 

Haemorrhage, meningeal, 84. 

into spinal cord, 162. 

spinal meningeal, 159. 
Headache, 307. 
Hemianopsia, 4. 

as localizing lesion, 41. 

lateral homonymous, 41. 

nasal, 41. 

temporal, double, 41. 
Hemiopia, 4. 

Hemiplegia, pretended, 101. 
Hereditary ataxia. 226. 
Hydromyelus, 176. 
Hydrophobia, 399. 
Hyperemia of the brain, 74. 
Hyperesthesia, 3, 147. 
Hvpoglossal nucleus, lesion of, 216. 
Hysteria, 353. 
Hystero-epilepsy, 360. 

Infantile paralysis, 195. 
Internal capsule. 20. 

course of fibers leading from, 23. 

fibers, order of, 36. 

lesion of, 40. 



INDEX. 



413 



Internal capsule, sensory fibers, 36. 
Island of Reil, lesion of, 48. 

Kak-ke, 266. 

Labio-glosso-laryngeal paralysis, 215. 
Landry's paralysis, 192. 
Laryngeal crises, 232. 
Lateral sclerosis, 250. 
Lead colic, 390. 

poisoning, 390. . 

poisoning in myelitis, 180, 188, 
391. 
Lenticular nucleus, 21. 

functions, 37. 

lesion of, 39. 
Leptomeningitis cerebralis, 53. 

spinalis, 152. 
Local asphyxia of the limbs, 322. 
Locked- jaw, 379. 
Locomotor ataxia, 224. 

Mania in cerebral anaemia, 72. 

a potu, 395. 
Megrim, 311. 
Meniere's disease, 330. 
Meningeal haemorrhage, cerebral, 84. 

spinal, 159. 
Meningitis, cerebral, 50. 

cerebral, chronic, 58. 

cerebral, local, 58. 

spinal, 149. 

tubercular, 61. 
Micturition, disturbed, in disease of 

spinal cord, 144. 
Migraine, 311. 

Monospasm in meningitis, 58. 
Motion, accelerated, 141. 

retarded, 141. 
Motor centers, lesion of, 38. 

spasm in lesion of, 38. 
Motor power, methods of testing, 5. 
Multiple neuritis, 266. 

sclerosis, 242. 
Muscles supplied by motor nerves, 

140. 
Myelitis, 179. 

acute, 179. 

of anterior cornua, 195. 

of anterior cornua in adults, 199. 

chronic, 188. 

from lead, 391. 
Myxocdema, 386. 

Nephritic crises, 231. 
Nerve, eighth, origin, 31. 
fourth, connection with sixth, 28, 
30. 

fourth, origin, 28. 



Nerve, seventh, origin, 29. 

sixth, origin, 29. 

sixth, paralysis of, in lesion of 
pons, 45. 

third, connections with sixth, 28, 
30. 

third, nucleus, lesion of, 43. 

third, origin, 27. 

third, disease of, 259. 
Nerves of medulla, 31. 

peripheral, distribution to muscles, 
140. 

syphilis of, 409. 
Nervous exhaustion, 371. 

cause of anaemia of brain, 69. 
Neuralgia, cervico-brachial, 275. 

cervico-occipital, 274. 

dorso-intercostal, 275. 

lumbo-abdominal, 276. 

sciatica, 276. 

trifacial, 274. 
Neurasthenia, 371. 
Neuritis, 261. 

multiple, 266. 
Nutrition, 12. 

Ophthalmoscope, importance of, 4. 
Optic chiasma, decussation in, 26. 
Optic nerves, 26. 

neuritis, in cerebellar lesion, 46. 

neuritis, in myelitis, 185. 

neuritis, in tumor of brain, 119. 

thalamus, 22. 

thalamus, function, 37. 

thalamus, lesion of, 39. 

thalamus, nutrient arteries, 32. 

tract, 26. 

tract, central origin, 27. 

Pachymeningitis, 50. 

cervical hypertrophic, 149. 

external, 50. 

internal hemorrhagic, 51. 

spinalis externa, 149. 

spinalis interna, 149. : 

Painful points, 272. 
Paralysis, acute ascending, 192. 

after acute diseases, 294. 

after diphtheria, 294. 

agitans, 329. 

alternate, 43. 

brachial plexus, 293. 

bulbar, 215. 

facial, 289. 

from pressure, 285, 293. 

infant ilc, 195. 

Landry's, 192. 

lead. 391. 

local, 285. 



414 



IXDEX. 



Paralysis of motion, significance in 
disease of spinal cord, 139. 

ocular muscles, 289. 

peripheral, 285. 

pseudo-hvpertrophic, 255. 

reflex, 286. 

rheumatic, 285. 

seventh nerve, 289. 
Paraphasia, 48. 
Parkinson's disease, 339. 
Petit mal, 344. 
Photopsia, 42. 

Pia mater, inflammation of, 53. 
Points apophysaires, 272. 

douloureux, 272. 

painful, 272. 
Poisoning, arsenic, 394. 

lead, 390. 
Poliomyelitis, anterior acute, 195. 
in adults, 199. 
in infants, 195. 

anterior chronica, 202. 
Pons Varolii, lesion, 44. 

sensation in lesion of, 45. 
Post-hemiplegic chorea, 335. 
Professional cramp, 304. 
Progressive muscular atrophy, 207. 

hereditary, 212. 

juvenile form, 212. 
Prosopalgia, 274. 

Pseudo-hypertrophic paralysis, 255. 
Pseudo-meningitis in children, 73. 
Pulvinar, function of, 37. 

lesion of, 41, 42. 
Pupil, contracted, in lesion of pons, 
45. 

changes in, 4. 

reaction in cerebral lesion, 42. 
Pyramidal columns, 135. 

Reaction of degeneration, 6. 
Reflex action described, 6. 

in lesion of spinal cord, 142. 

centers in spinal cord, 8. 
Reflexes, cutaneous, 7. 

deep, 8. 

patella tendon, 8. 

tendon, 8. 
Respiration, Cheyne-Stokes, 10. 
Retarded motion, 141. 

Saint Vitus's dance, 332. 
Sciatica, 276. 
Sclerosis, 242. 

amyotrophic lateral, 252. 

lateral, 250. 

multiple, 242. 

posterior spinal, 224. 
Sensation, changes in, 3. 



Sensation changes, lesion of spinal 

cord, 147. 

methods of testing, 1. 

in unilateral lesion of spinal cord, 
147. 
Sense, muscular, testing, 2. 

of pain, testing, 2. 

of pressure, testing, 2. 

of temperature, testing, 2. 

of touch, testing, 1. 
Sensory fibers, course of, 36. 

in pons, 45. 
Sexual function perverted in dis- 
ease of spinal cord, 145. 
Shaking palsy, 339. 
Sick headache, 311. 
Sleeplessness in anaemia of brain, 74. 
Spasm, 298. 

facial, 299. 

of diaphragm, 303. 

svmptom of lesion of motor cen- 
ters, 38. 

svmptom of lesion of spinal cord, 
'129. 
Speech, disturbance of, 46. 

in lesion of pons, 45. 
Spinal anaemia, 158. 
Spinal cord, anaemia of, 158. 

anatomy, 132. 

blood-vessels, 133. 

cavities in, 176. 

central canal dilated, 176. 

changes in blood-supply, 156. 

compression, 167. 

general symptomatology, 138. 

gray matter, 133. 

groups of cells, 133. 

haematorrhachis, 159. 

haemorrhage, 162. 

hyperaemia, 156. 

inflammation, 179. 

length, 133. 

membranes, 132. 

meningeal haemorrhage, 159. 

physiology, 136. 

pia mater* inflammation of, 152. 

sclerosis of lateral columns, 250. 

sclerosis of posterior columns, 224. 

slow compression, 167. 

symptomatology, 138. 

syphilis, 408. 

unilateral lesion, motion in, 139. 

unilateral lesion, sensation in, 147. 

white substance, 134. 
Spinal dura mater, inflammation, 
149. 

hyperaemia, 156. 

irritation, 373. 

leptomeningitis, 152. 



INDEX. 



415 



Spinal dura mater, meningeal haemor- 
rhage, 159. 

meningitis, 149. 

pachymeningitis externa, 149. 

pachymeningitis interna, 149. 

tumors, 173. 
Status epilepticus, 346. 
Symmetrical gangrene, 322. 
Sympathetic, diseases of, 307. 
Syphilis of the brain, 403. 

hereditary, 409. 

of the nerves, 409. 

of the spinal cord, 408. 
Syringomyelia, 176. 

Tabes dorsalis, 224. 
Tache cerebrale, 9. 
Temperature in cerebral haemor- 
rhage, 94. 

embolism, 109, 111. 
Trophic changes in cerebral haemor- 
rhage, 99. 
Tendon reflex, 8. 

absent in lesion of spinal cord, 143. 
Tetanus, 379. 
Tetany, 383. 
Thomsen's disease, 303. 
Thrombosis of cerebral arteries, 112. 
Tonic spasm, 298. 



Toxic neuroses, 389. 

Torticollis, 301. 

Tremor, 298. 

Trismus, 380. 

Trophic centers in spinal cord, 137. 

changes in lesion of spinal cord, 
145. 
Tumor of brain, 116. 

spinal cord, 175. 

spinal meninges, 174. 
Tiirck, columns of, 135. 

Urine, retention, 12. 

Ventricles, haemorrhage into, 95. 
Vertebrae, cancer, 167. 

caries, 167. 

tender, 148. 
Vertigo, 329. 

in cerebellar lesions, 46. 
Vision, alterations of, 3. 

mode of examining, 4. 
Visual centers, lesion of, 42. 
Vomiting in cerebellar lesion, 46. 

"Word blindness, 48. 

deafness, 48. 
Writer's cramp, 304. 
Wry-neck, 301. 



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University of Ireland ; Fellow of the Academy of Medicine in 
Ireland ; and of the Obstetrical Society of London, etc. 1 vol., 
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" Within a very moderate compass, this work covers the field of gynaecology quite 
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tion, but also in that which is not less useful to the ambitious neophyte — salutary admo- 
nition." — Canada Lancet. 

Atlas of Female Pelvic Anatomy. By D. Beery Hart, M. D., 
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School of Medicine, Edinburgh, etc. With Preface by Alexan- 
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" Within recent years much has been done to weed the topographical anatomy of the 
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labor, he has entered with all his accustomed vigor. . . . The ' Atlas ' deserves, and will 
surely have, a wide circulation ; and we are confident that no one will rise from its careful 
perusal without having obtained clearer, more accurate, and more intelligent views in re- 
gard to the much-vexed questions of female anatomy, or without having formed a very 
high opinion of the author's industry, earnestness, and ability." — Edinburgh Medical 
Journal. 

A Manual of Dermatology. By A. R. Robinson, M. B., L. R. C. 

P. and S. (Edinburgh), Professor of Dermatology at the New 
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Revised and corrected. 8vo, 647 pages, cloth, $5.00. 

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THE 

NEW YORK MEDICAL JOURNAL, 

A WEEKLY REVIEW OF MEDICINE, 



Published by 

D. APPLETON & CO., ( P. FC ,M.D., 



Has for its principal features Lectures, Original Communications, Clinical 
Reports, Correspondence, Book Notices, Leading Articles, Minor Para- 
graphs, News Items, Letters to the Editor, Proceedings of Societies, Re- 
ports on the Progress of Medicine, and Miscellany. 

So rapidly has the Journal gained in public favor that it is now acknowl- 
edged, to be the Leading Journal of America. It numbers among its 
contributors many of the most eminent men in the profession, whose papers are 
valuable additions to medical literature. The Society Reports, of which 
each number of the Journal contains several, are full of interesting and in- 
structive matter. The Reports on the Progress of Medicine, written 
by men especially qualified in their respective branches, cover the most recent 
advances in medical science. Current events of the day are treated under the 
head of News Items, from a medical stand-point. Everything new and use- 
ful in materia medica is chronicled under the head of Miscellany in '' Thera- 
peutical Notes," which appear weekly, and are alone well worth the subscription 
price of the Journal. 

The arrangement of the matter in the Journal enables us to furnish a greater 
amount of reading-matter in its twenty-eight double-columned pages than is 
given by any other journal of its class in America. Illustrations are more freely 
given than in most journals, and are, as a rule, much better executed. 

To the physician who desires to keep abreast of the times in medicine and 
surgery, "The New York Medical Journal" is an indispensable requi- 
site, and to the Advertiser who wishes to reach the medical profession it is a 
medium second to none, as its rapidly increasing circulation, distributed through- 
out the entire Union, will abundantly prove. 



TERMS, PAYABLE IN ADVANCE. 
One Year - - $5 °o 

Six Months - - - - - - - - =2 50 

(]fo subscriptions received for less than Six Months.) 
Binding Cases (for permanent binding), Cloth, per volume - 50 

The Popular Science Monthly and The New York Medical Journal to the 
same address, $9.00 per Annum (full price, $10.00). 



New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 



